How to Deal with Chronic Pain: Psychological Causes and Treatments

Chronic Pain in lineWe like instant gratification. Who doesn’t? You desire a thing, you want it as soon as possible. This is entirely rational. The food looks good, you’re (relatively) hungry, so let’s eat. That gadget would be fun to play with, you’ve got the money (or credit) for it, so let’s buy it. This is why we sign up for and can never relinquish our Amazon Prime same-day shipping, why we demand antibiotics for viral infections, and why we can purchase and collect entire buckets of fried chicken without ever leaving our cars. We don’t like to wait if we don’t have to. And we rarely have to wait. This extends to how we deal with physical pain: my arm hurts, I want this pain to go away right now, so I’ll take a painkiller.

The problem with this approach to pain is that the quick solutions rarely work like they do for other physiological messages. Hunger is simple. You put something in your mouth, chew, and swallow. Hunger gone. But pain is complex. Pain is communication. When something hurts, your nervous system is telling you that something is wrong with your body (that stove is hot, your ankle is sprained, you pulled your hamstring) and you should fix it (pull your hand away, elevate and stay off your ankle, warm-up before you sprint next time). People born without the ability to feel pain are extremely vulnerable to death and dismemberment. It might sound cool to live without pain, but we desperately need it to survive.

Acute pain can usually be trusted. Chronic pain is trickier. There may have been initial tissue damage, but instead of decreasing the pain as the damage healed, it increased: chronic pain usually gets worse, not better.

How does the conventional medical system deal with most chronic pain?

Strong drugs: Opioid painkillers don’t work. Well, they “work,” but a little too well. You have to keep taking them to keep the pain at bay in increasingly larger doses, which increases the risk of addiction. They don’t actually help you heal or resolve the pain, and if anything, they increase your sensitivity to chronic pain. Dulling the pain or killing it with strong drugs usually doesn’t fix the underlying problem. Especially for chronic pain—the kind of pain that lingers and follows you through life—magic bullets don’t really exist. It’s no wonder that millions of Americans are addicted to prescription opioids like oxycodone.

Surgery: Though it’s great for acute tissue damage, surgical interventions for chronic pain have mixed results. Back fusion surgery outcomes are generally inferior to non-surgical interventions, and failed back surgeries have the potential to increase chronic pain and dysfunction. That a condition called “failed back surgery syndrome” even exists is telling. And research pitting knee surgery against placebo knee surgery suggest that arthoscopic knee surgery may not be required to “fix” chronic degenerative meniscus tears.

Pain is an output from the brain, not an input from the body.

When tissue is threatened/damaged/burned/lacerated/sprained, peripheral nerves called nociceptors send alarm signals to the brain, but the brain must interpret those signals and decide if you should “feel pain” or not. Utility determines pain: you’ll feel it if it’s helpful. The basketball player who sprains his ankle in the 2nd quarter of a pre-season game will immediately feel it, because his brain wants him to rest instead of finishing out the game. If that same injury occurred in game six of the NBA finals, his brain might “allow” him to continue playing because the stakes are so high. The soldier whose leg was mangled by a grenade probably won’t feel pain commensurate with the damage done, because his brain wants him to drag himself to safety.

Physical damage doesn’t always cause pain, and you don’t even need to possess the supposedly painful tissue to feel pain in the tissue. Consider phantom limb pain, where amputees still feel pain in the missing limb. There’s no limb to hurt, no nerves to send or receive signals, yet it still hurts. Thank the brain.

First off, I’m no doctor. Like anything involving the brain, chronic pain can be incredibly complicated. What I can offer are a few low-impact, non-interventional Primal ideas for improving your pain situation. I won’t be telling you how to adjust your own spine or anything like that. In fact, I’ll save the physical interventions for another post. Today is all about the psychological causes and fixes for physical chronic pain.

What are some things to consider?

Try the Sarno Method

A doctor of rehabilitation, for years Dr. John Sarno had seen back pain patients treated the conventional way. Throw ’em in the imaging machine, identify bulging discs or other trauma, and go from there. Sometimes it was surgery, sometimes physical therapy. It rarely worked. Then he realized something wild: while almost everyone had some sort of physical trauma to their back, the pain they felt didn’t always correlate to the site of the trauma. Someone might have a bulging disc at the L1/L2 but feel pain higher up, or vice versa. Furthermore, back surgery to fix the trauma rarely reduces pain. And acute back injuries, like a crushed disc hurt like hell but usually stop hurting after a few weeks, just like a broken leg. What Sarno discovered is that a lot of chronic back pain stems from bottled up stress, anger, or repressed emotions. The psychological pain becomes physical. Sarno dubbed this tension myositis syndrome, or TMS.

The Sarno method has two phases:

  1. The patient must address the psychological causes of the pain.  They didn’t necessarily have to fix the problems causing the stress and emotional turmoil, but they do have to acknowledge their existence and confront them head on.
  2. Since the root cause is psychological, not physical, the patient must resume physical activity. This is crucial. You have to “prove” to your brain that your body isn’t suffering from physical trauma that would restrict movement.

A 2007 study confirmed it: the Sarno method works for back pain patients without specific structural pathologies, especially those with chronic pain. Many patients find that merely reading Sarno’s book, even just the introduction, reduces their chronic back pain. They aren’t medical references, but check out the gushing reviews on Amazon for Sarno’s book. Just becoming aware of the psychological origin of the pain is often enough to fix it.

Learn about pain science

A funny trick about pain is that merely learning about how it works can often reduce it. This may have happened just a few paragraphs back when you read about the brain interpreting signals from the nerves and deciding whether or not to send pain back.

First of all, everyone can learn and understand it. Doctors may think it’s too confusing for most patients, but in 2003 they actually tested this. Chronic pain patients with inaccurate conceptions of pain science were able to understand the neurophysiology of pain when it was properly and accurately explained (even the doctors improved their knowledge of pain science).

Second, learning about pain neuroscience can reduce chronic pain. An older systematic review of the literature concluded that educating chronic pain sufferers about pain neurophysiology and neurobiology has a “positive effect on pain, disability, catastrophization, and physical performance”; a 2016 review came to the same conclusion.

To learn more abut pain science (and hopefully improve your own chronic pain), look no further than Todd Hargrove, whose book and blog offer great insight into the physiological origins of—and potential solutions for—all types of pain.

Deal with, or at least acknowledge, the major stressors in your life

This isn’t an easy or even simple solution. Stress is hard and the things that cause stress are numerous and unending!

But if there are any obvious ones, any real whoppers, take them on.

Bad relationship? Address it. Try counseling. Try a “we need to talk.” Don’t ignore the issues and tell yourself it’s okay. Your brain knows it’s not okay, even if you’re trying desperately to convince it otherwise.

Hate your job? No one should spend 40+ hours a week doing something they loathe. It’s not healthy. And research out of the US shows that people who hate their job are more likely to progress from acute to chronic pain. Chronic pain is more common among dissatisfied workers in Japan, too.

Plagued by a perpetually messy house? Don’t just walk by those dirty dishes for the tenth time this week. Clean them, go minimalist, or hire a de-clutterer. Or all three.

It’s different for everyone—I can’t anticipate every stressor in everyone’s life—but this all boils down to “don’t run away from your problems.” You must at least acknowledge them (remember the Sarno method?).

Understand that fear may be holding you back and making the pain worse

Pain needs fear to work. When you touch that hot stove or prod that wasp nest, the pain you receive scares you away from repeating the mistake in the future. As a response to acute pain, fear-avoidance works—it prevents future instances of pain. As a response to chronic pain, fear-avoidance worsens outcomes and hastens the progression to disability. Research has found that among people with chronic pain, those exhibiting more fear-avoidance are more likely to become disabled, to miss work, and to avoid normal daily activities.

But pain-avoidance doesn’t just predict bad outcomes; it also has real effects. The more they avoid the activities they assume will cause pain, the worse they get. Their muscles atrophy. They actually get more sensitive to pain. In one controlled trial of patients with chronic low back pain, inducing “pain anticipation” before a behavioral test reduced performance and increased pain. As some pain researchers put it, the fear of the pain is more disabling than the pain itself.

Consider how being scared of your pain goes down: you live in a constant state of anxiety, worried that one wrong turn or miscalculated twist of the body will send you reeling to the floor.

In the end, it’s no different than being wracked with physical agony. You’re scared to move. You think about pain all day. You curtail your normal existence. Your fear of pain has disabled you.

Increase the stakes of painful movements

Recall how the NBA player turning his ankle in a pre-season game is more likely to feel it and take a couple weeks off than if he were to turn it in a playoff game. Pain is a negotiation, it’s the culmination of the brain deciding whether the stakes are high enough for you to keep doing the activity that triggered the nerves to send the “pain request” signal. You can control the stakes and thus affect the negotiations.

Get some competition in your life or join a team sport; if people are counting on you or you’re up against your arch nemesis, your brain is more likely to turn down the chronic pain to let you participate. If you’re walking ten miles to raise funds for cancer research, maybe your foot or back or knee won’t hurt so much.

Live the good life

A big part of the pain response comes from the brain’s assessment of your overall situation: if things in general are bad, it’s more likely to err on the side of causing pain. Research into the psychosocial causes of non-specific chronic low back pain in Japanese adults finds that anxiety, life dissatisfaction, and feeling underappreciated at work have the most predictive power. Sound familiar?

Do things that make you happy. Take warm baths at night with a good book. Hang out with friends; don’t be a hermit. Get some midday sun, work on that promotion, build that business you’ve been milling over for years. Improve the quality of your life. Avoid regret. There are innumerable ways to improve your life and increase happiness.

Know that it’s not “all in your head”

Pain comes from the brain, true. It’s the result of the brain’s deliberation over the situation, true. The brain decides if you feel pain or not, true. But the pain is real. You’re not crazy, you’re not “imagining” the pain. The brain isn’t conjuring pain without reason. You may not agree with the reason, and the physical damage to the tissue may not warrant the amount of pain you currently feel, but there’s still a there there.

That’s it for now, folks. Next time I’ll discuss some “physical” causes of and treatments for chronic pain, but for now be sure to direct any comments and questions down below.

Do you experience chronic pain? Does any of this ring true for you?

Thanks for reading!

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About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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38 thoughts on “How to Deal with Chronic Pain: Psychological Causes and Treatments”

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  1. Thank goodness you’re no doctor. If you were, I would have crossed this website off my list a long time ago. Most doctors understand only drugs and surgery, both of which often create additional problems. Many of us–maybe even the vast majority of us–prefer natural, non-invasive options for healing our bodies. Thanks for a good article.

  2. I can highly recommend Paul Ingraham’s blog for some very well-researched articles on pain and injury recovery! Much of what I’ve learned is similar to what was provided in this blog post, but with lots of science-y details (and a sense of humor that makes it all a bit easier to swallow).

  3. Thanks for this – I have chronic migraine – a slightly weird one where the brain thinks there is a problem when in fact it is making up a problem (no physiological damage exists). I am using Dr Turknett’s (a neurologist who ‘cured’ his own lifelong migraine) approach and one of the first and most important things he advocates is no more painkillers as they down regulate the brain’s own pain relief. I imagine this would apply to all types of pain – sometimes in extreme situations pain relief is applicable, but in chronic pain this is a really important message and has transformed my life even if the process is extremely hard work – not to mention… painful. More info on this at Dr Turknett’s mymigrainmiracle website and book. The other thing recommended by Dr T and which would resonate with the above is Michael Singer’s book which teaches you how to separate your fear of pain and your thoughts and emotions about pain, from yourself – your pain is not you so there is no need to be dragged into the cortex of it . I find both the medication reduction/ elimination and the ideas in M Singer’s book extremely helpful for chronic pain .

  4. Interesting! I’ve never experienced this, but I have seen this with a friend’s husband. He suffered from debilitating, all-day-every-day headaches and they simply could not find a cause. And then he changed jobs, and the headaches suddenly went away. Turned out it had been job stress manifesting in crippling headaches.

    Good information here – thanks!

  5. I’m really glad for this article just now. I have a very painful knee, and I don’t want to go to the doctor – he will just want to send me in the direction of surgery, or give me a cortisone shot, or tell me to take painkiller meds. Instead I did some research about foods, supplements, and exercises for knee pain. I’m also convinced (even more after reading this) that my psychological state will matter. Each time I take the supplements or eat the healthy foods, I imagine them sending goodness to my knees and stimulating healing. I went swimming in a very cold spring – that was wonderful! Not only did the cold water help, but the natural beauty…and just sheer fun of it!…distracted me from the pain. Music really helps also…when I’m listening or rehearsing with my band, I forget the pain entirely. I’m thankful for the supplements, the food, the exercise, the cold spring, and this website, where I have learned so much. I’m believing that my amazing knee, which is “fearfully and wonderfully made”, will heal.

  6. Wow, really interesting post. I had heard of Sarno before and his work sounds really interesting. My daughter suffered from a pain condition called RND (Reflex Neurovascular Dystrophy.) It is sometimes called Complex Regional Pain Syndrome. It is severe pain, usually in an extremity, and often after an initial injury has healed. In her case it was after a broken ankle. The pain became so severe that my athletic daughter couldn’t walk. She received inpatient treatment at a children’s rehab hospital in Pittsburg. Interestingly, like Sarno suggests, much of her treatment involved physical activity, actually working through the pain. And with the talk of meds at the beginning of this piece, there was no medication that touched her pain when the condition was at its worst.

  7. Acupuncture does a lot of amazing things (it literally changed my life and saved my profession), but it really shines with acute and chronic pain. And don’t just try it once and then say “it didn’t work for me”. You’ wouldn’t use that standard for anything else in your life (I took a vitamin and it didn’t work). Work with your practitioner or try a different one. Just like any profession, there’s a wide range of abilities and experience. Not all acupuncturists are the same. Like doctors, some are excellent and some not so much.

  8. I would love to hear your views on Neuro Emotional Technique – a chiropractic Kinesiologiy treatment that very effectively, and quite quickly, deals with emotional issues and associated physical pain. I personally have had great success as a patient over many years but would love your opinion.

  9. Dr Sarno’s books helped me overcome chronic back pain. The main “stressors” in my case was bad relationships and chronic unconscious anger about that. The pain has not come back since I stopped letting men mistreat me.

  10. i have been dealing with what i thought was chronic plantar fasciosis, but what i just found out was actually heel fat pad atrophy for the past four or so years. it has literally stopped me in my tracks, both physically and emotionally. i can no longer dance, run, let alone, walk, or even stand without considerable pain. I am only 26 years old and i feel helpless and hopeless

  11. I had a chronic pain in the knee due to a tendinosis in the patellar tendon. After 2 years I almost completed recovered. I’ll write about this in some Argentinians forums but I’m not completely recovered.
    Is possible to regenerate the tendons you have to address an osteopathy, postural correction, eccentric exercise, low impact exercise, paleo food 100%, intermittent fasting, fish oil, try a foam roll, EPI.
    Lots of hard work, but it works.

  12. Whenever something hurts – pain in the shoulder or headaches – I look for the cause. Like sitting too high or too low or not 90 degrees to the desk. Or the hairclips on my hair causing headache. Or bad glasses. Or a mattress that was too soft in the wrong places causing migraines that lasted days. Or a keyboard with numpad. A laptop keyboard really helped with the shoulder.

    PS: the new look of the website is great. But when writing a comment the text is mid grey that doesn
    t have a good contrast to the white background.

  13. There is a trend to classify all chronic pain as solely a fabrication, albeit, one beyond the control of an individual. Please don’t discount on-going physical issues as a source of chronic pain. Not all problems can be successfully fixed with surgery – indeed, surgery can cause or worsen many pain problems. That leaves drugs with their well-known side effects and lack of curative ability. For some, their fear of activity is based on very real, negative physical consequences – eg worsening pain, worsening function. Living with chronic pain for many people also involves identifying the physical aspects and how best to work the specifics of each situation. Yes, exercise is important. Yes, meditation is important. Yes, social support is important. But of some of us, it is not enough to just ignore the pain and continue with our lives – we must cope with the physical causes and consequences daily.

    1. You don’t have to live with chronic pain. Check out Nicole Sachs’ YouTube channel: The Cure for Chronic Pain

    2. Lissa, I’m inclined to agree with you. Mark closed by saying that the pain is real, and I heartily concur.

      For some of us, chronic pain is a running together of episodes of acute pain – and acute pain can be trusted! My spine is twisted, and it has good reason to hurt. I have seen the x-Rays, discussed the situation, do exercises, and live a pretty good life doing what I love – I’m an archaeologist. I avoid torquing my spine, as I already have rotated vertebrae, and protect my lumbar vertebrae by avoiding actions with compressive force. When the pain sets in, I stop
      and stretch, or lie down flat for 5 minutes. The only anger I have is for people who try to convince me that drinking lemon juice or thinking good thoughts or whatever their true belief will magically destroy the pain. My back, my life, my career. I don’t repress that anger either!

      The same with chronic migraine. After 51 years of migraine, 30 of them invested in understanding my disorder and learning to manage it.

      I sometimes go for several weeks without a migraine. When one strikes, I take a Naratriptan and a naproxen. 24 hours relief. I’ve identified a lot of triggers and avoid them. I know what works for me.

      I think there’s often a basic lack of respect for individuals’ experience, as well as a proselytizing fervour.

  14. I had chronic back pain for several years, and was totally into the “worried whether this was going to hurt” mindset that curtailed my activities. I haven’t had any back pain for quite a while tho, which I attribute partly to Sarno and partly to Todd Hargrove’s theories (though I actually only found his book recently, I stumbled on a similar approach).
    For the emotional angle, I can heartily vouch for Ann Weiser Cornell’s Focusing ( – my focusing partnerships gave me a way to examine a whole load of life issues I was having, and some of my sessions directly addressed pain I was feeling and lead me to understand how it was connected to certain emotions and traumas I had experienced.
    And my Todd Hargrove approach was basically careful movements that tickled up against the pain without going so far as to make it worse. I did a lot of deadlifts (starting VERY light and carefully) and also a lot of cobra-pose backbends (again VERY carefully) and this slowly retrained my brain to be comfortable with those movements. I now deadlift 1.75xbw (my goal 2x) and surf regularly with no pain (few things are more difficult with back pain than surfing).
    I also have a theory that foam-rolling/trigger point massage is really working at a brainlevel – Todd says that when your body map is deficient in a certain area it will misinterpret that lack of information as a problem and cause pain in that area – by pressing on “trigger points” you are stimulating that area of your brain’s body map and awakening your brain’s sensitivity to that area of your body – your brain is now getting enough information and so feels no need to generate pain in this area. This would perhaps explain “referred pain” – the areas pain is being referred to are in neighboring areas of the body map (tho not directly adjacent in the body).

  15. It’s amazing how just understanding how pain works and the function of it, the fact that it’s created in the brain and may or may not be accurately correlated to tissue damage, is a game-changer. It’s not an immediate fix for everyone, me included, but it opened the door for me to work through it one step at a time and finally make progress. Both Sarno and Hargrove helped me a ton along the way.

  16. I’ve never lived with chronic pain and can’t begin to understand the realities of it, but this article seems to offer good strategies for addressing pain that don’t involve medication. As an athlete, I’m always told to increase my pain tolerance, but when pain is a constant factor, I hope there are strategies that can make the pain manageable, and not just tolerable.

  17. Meditation and contrast showers help. I’ve read good things about Kratom but that’s getting banned in the near future.

  18. I have seen psychosomatic pain a lot in my relatively short time practicing physical therapy. I have recommended the Sarno book to many people but can also recommend this post now too! Thanks!

  19. I’m grateful to Dr. Sarno. I suffered sciatica for several months until I read one of his books. It turned out I was repressing the anger I had towards someone. Once I realized that, my pain dissipated. A few years later, I developed plantar fasciitis, and again same story.

  20. Interesting post. I see it as a chicken-and-egg situation – stress causes pain which causes stress. I have severe endometriosis and have lived with chronic pain for most of my adult life. It’s a fight not to give into the depression, hopelessness and frustration that comes from finding no answers and no cure (and yes, I’ve tried all the alternative/holistic remedies…some help, some not so much). Accepting that my body is flawed, and trying to love it despite that is an ongoing challenge.

  21. I take some enzymes and curcumin from time-to-time to help with intermittent pain, but chronic pain is definitely a life-altering issue that needs managed.

  22. I can vouch personally for Dr. John Sarno’s method. I had excruciating leg pain that got worse and worse and tried very expensive treatments (prolo therapy, dry needling, cold laser, ART, massage, acupuncture) to fix it. I couldn’t stand for more than five minutes without my legs turning purple and walking was out of the question. This was all at the age of 23-25.

    I read a few of his books and literally my leg pain was gone in about two days of practicing what he recommends. The thing is that it can start from a real injury, mine started after I was running way too much and got shin splints but then it just got worse and worse and didn’t make any sense.

    Sometimes I will have new pain pop up in different parts of my body and think something is so wrong with me and at some point I’ll think “this is out of control for what happened” and a lot of times it’s what Sarno calls “TMS” and it will go away after applying his principles. It’s shown up in my feet, hands and different parts of my legs.

    I highly recommend checking out John Sarno’s books if you’re experiencing muscle or back pain. It was literally a “miracle cure” for me.

  23. I’d like to share restorative yoga as a way of dealing with chronic low-back pain. It has helped me.

  24. Sarno’s approach worked for my back pain. I was having relationship issues that I was dodging, and I think my subconscious was trying to get my attention to do something instead of ignore the problems. I saw a therapist for a few sessions and came to grips with my issues and like magic, the back pain was gone. Now whenever I get a twinge in my back, I ask myself if anything is bothering me. Sometimes it is an actually injury/tweak but often it is an issue I’ve been neglecting.

  25. “Pain is the greatest gift a person can have, but it’s a gift that no one wants”

  26. Another great article! My mother-in-law suffered from chronic pain for years and tried to fix it with a back surgery, which only made things worse. She passed away within a year. I wish everyone with chronic pain would read this article and Healing Back Pain by Dr. Sarno. I didn’t discover this information until it was too late to help her.

  27. This is intriguing, but I don’t know if it’s ultimately helpful. I started noticing chronic tightness in my lower back about when I turned 30. I’m 35 now. It hasn’t really gotten better or worse. I’d really like to figure it out. If I do yoga stretches that target it, it feels really good, but doesn’t seem to offer any medium/long term relief.

    I would be interested in some kind of systematic approach to rooting out the underlying stress and other issues causing it.

    1. Hi Marty, I’ve been dealing with on and off low back pain for years, apparently due to an unhealthy disc from too much hole digging and landscape work when I was younger. Yoga helped a little, and my chiropractor can be a real help from time to time. Two things helped the most though.. Regular strength training in the form of deadlifts, kettle bell swings, and hypers. All great for strengthing the low back, and maybe a signal to the brain that everything is ok! Get a coach to show you all. Also, Google “couch stretch”. Often when my back feels tight, my hips also are. I’m in my fifties now, but can still go for long runs and hikes in the mountains. Not totally pain free, but very manageable.

  28. Very well written article with lots of good information. I completely agree that you should acknowledge the major stressors in your life, they play a big part in your psychology and translates into your body as well.

  29. Thank you so much!! I’m pretty sure I have tension myositis syndrome (or whatever the name). I don’t think it explains all my symptoms and I’m kind of caught overthinking what could be it and what couldn’t be it but I’m still pretty sure it will help me tremendously!

    Seriously, I read somewhere that you should stop any diet and but I’m pretty sure I can’t start to eat casein right out the blue. I know that maybe it’s only fear (or the nocebo effect) but I don’t care. Also, I don’t think I’ll stop taking my supplement either.

    Basically, I’m a little bit confused but highly hopeful!

  30. Entertaining article. I have long had chronic pain and am taking opioid painkillers. I have tried many different techniques, methods and preparations. Various sports and other activities, but nothing helps me, I can’t find what makes me special from this pain.
    But I will try the tips that you give in your article.