Is chronic pain all in your head? The answer could be yes.

| Steve Bieler

They don’t make pain like they used to. Just ask Daniel Clauw, M.D.

“When I was trained as a rheumatologist 30 years ago, we didn’t know anything about the role of the brain in who has pain and who doesn’t,” he says. Clauw is the director of the Chronic Pain and Fatigue Research Center at the University of Michigan and a member of the Chronic Pain Research Alliance Scientific Advisory Council. 

“We thought everyone with the same diagnostic label could be treated uniformly for pain,” says Clauw. “Well, you can’t treat chronic pain based on the label. You have to ask, ‘What is the underlying mechanism that is driving the pain?’ ”

If, for example, your first experience of chronic pain is painful menstrual periods when you’re 15, you’re likely to end up with the label of primary dysmenorrhea. For another example, if the pain is in your jaw, your doctor or doctors might label it temporomandibular joint dysfunction. But the source of the pain might not be in your uterus or in your jaw. 

“It’s not uncommon for patients to get two, three or more labels in their lifetimes to fit the places in their body where the pain first showed up,” Clauw says.

For many patients, chronic pain might come from the part of the body damaged by an injury or a condition such as psoriatic arthritis (PsA). This is the type of pain that you can point to with your finger. But your pain might also come from the brain and central nervous system. If the pain is actually in your brain, Clauw says, you won’t point, you’ll make a circle. And that circle could move. 

Pump up the volume

Clauw says we have a volume control setting that our brain uses to process pain. He gives as a metaphor the amplifier for an electric guitar. 

The setting of your amplifier may have just as much to do with the pain in, say, your knee as what’s physically wrong with your knee. “People with a lot going on in their knee might not feel any pain,” Clauw says. “But other people might have a higher amp setting. The knee is not where the fundamental problem is in those conditions. The fundamental problem is the volume setting,” he says. “It makes everything seem to hurt.” 

Pain that emanates from the amplifier in the brain is called centralized pain. Clauw says it’s common in conditions involving the immune system. It’s usually accompanied by other central nervous system symptoms, such as fatigue, mood changes, sleep disorders and memory loss. 

“Women on average have inherently higher volume control settings than men,” Clauw says. He estimates that chronic pain disorders are up to twice as common in women as in men.

What this means for patients with PsA

Clauw believes that roughly half of all patients who have PsA experience some degree of centralized pain — and for these folks, treating the joints involved with anti-inflammatories, biologics or other therapies might not ease the pain. This is because centralized pain extends beyond the joints.

He speaks candidly to patients in a YouTube video. “One of the problems we have in pain treatment is that all of our drugs sort of suck,” Clauw says. “They’re only modestly effective. Your hypertension can be managed with drugs, but not chronic pain.” Nonsteroidal anti-inflammatory drugs, for example, work well for pain from actual injuries, such as a broken leg. They most likely won’t help with pain from the brain.

Clauw doesn’t rule out the use of medications for pain. However, he also favors non-drug therapies to help control symptoms, such as exercise, yoga, tai chi, acupuncture, mindfulness, good sleep habits, cognitive behavior therapy and stress reduction. 

Think you might have chronic pain?

If you believe you have chronic pain, talk with your health care provider about ways you can manage it. You can also check out NPF’s Chronic Pain Management Hub for more information on PsA and on drug and non-drug therapies.


Driving discovery, creating community

For more than 50 years, we’ve been driving efforts to cure psoriatic disease and improve the lives of those affected. But there’s still plenty to do! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funds to support research by joining Team NPF, where you can walk, run, cycle, play bingo or create your own fundraising event. If you or someone you love needs free, personalized support for living a healthier life with psoriatic disease, contact our Patient Navigation Center. And keep the National Psoriasis Foundation going strong by making a donation today. Together, we will find a cure.

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