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Anxiety & Chronic Pain

A self-help guide for people who have both anxiety and chronic pain

updated (first published 2006)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

Conversations about chronic painful problems routinely turn into conversations about anxiety. It begins with a statement like “I hold a lot of tension in my back” or “This pain is always the worst when I’m under a lot of stress.” And it often ends up at the chicken and the egg question: did anxiety cause the pain, or is the pain causing the anxiety? (Hint: it’s both.)

Excessive and chronic anxiety is a potent root cause for an awful lot of back pain, probably neck pain,1 as well as virtually any other kind of chronic pain,2 and even a bizarre array of other physical symptoms3 (WebMD has a good complete list). It almost certainly amplifies pain perception and suffering across the board, but it gets worse: it may also actually cause pain we wouldn’t otherwise have, by actually making us more prone to inflammation.4 Although the treatment of anxiety is outside my own expertise, as a “pain guy” it feels like familiar territory to me: anxiety is the other side of the chronic pain coin.

Anxiety is a feeling of worry, nervousness, or unease. Generalized anxiety disorder (GAD) occurs when that feeling gets chronic, excessive, uncontrollable, irrational, and associated with surprisingly diverse symptoms. At least 3 symptoms must drive you nuts for 6 months for a formal GAD diagnosis.5

Some anxiety is essential for our survival — a prehistoric human that didn’t worry wouldn’t live long — but it probably evolved as a strategy for anticipating and neutralizing threats that we no longer face. Anxiety disorders are a frustrating glitch in the modern human condition. Treating them can be like like fighting smoke. The basics of therapy for anxiety are obviously insufficient for most people. Exercise is valuable, but most people can’t beat anxiety just by working out, especially if they are in pain. This article zooms in on some practical, creative, and efficient strategies for calming down and “hacking” anxiety — extra tools for an “everything but the kitchen sink” approach.6

There’s also some whimsy. Because anxious people need some of that.

Medical causes of anxiety: anxiety as a symptom

Anxiety is rarely just about biology or psychology. Except when it is.

We humans are chemistry, and nothing could make this clearer than the chilling story of an old family friend who suffered lifelong anxiety and panic attacks. After decades of living with this curse, he was diagnosed with a rare genetic disorder. One of the consequences of this genetic disorder are small tumours on the adrenal glands that cause spikes in adrenalin production. He had one on his adrenal gland. The gland was excised, and he was cured — or perhaps “set free” would be a better description.

That’s an exceptionally rare cause of anxiety, of course. But don’t neglect the possibility of a medical explanation or complication. Some of them are much, much more common. For instance, we know that insomnia is a major risk factor for anxiety disorders,7 so anything that interferes with sleep — practical or pathological — is obviously an important consideration.

Or pain: pain is extremely common, and can be both the cause and consequence of anxiety — sometimes equally, sometimes slanted much more one way than the other, but each always influencing the other to some degree. For many people with both anxiety and pain, solving the pain is the best possible treatment for the anxiety. Others must solve both at once. And a few will find that pain is just one of many ways that they are haunted by anxiety demons.

Anxiety can be magnificently destructive, but when combined with chronic pain it becomes paralyzing.

How I learned to cope with chronic pain, Ettenberg (www.theguardian.com)

Another interesting example, and a bit chilling, with a strong tie-in to chronic pain: some people may be anxious because they have irritated spinal cords, which occurs in some arthritic necks and can cause the body to react as if it were stressed.8 It’s also been found that many people with fibromyalgia also have erratic spinal cord compression,9 which has profound implications: fibromyalgia might not only associated with stress, but also with “artificial” stress brought on by a mechanical spinal cord irritation.

Never in the history of calming down has anyone ever calmed down by being told to calm down

That’s not strictly correct, but it is funny because it’s true in a sense. Being told to calm down in the right way can be very effective. But that “right way” is maddeningly elusive. Most people feel like being persuaded out of anxiety is a tall order; it’s hard to outsmart it, or suppress it by force of will. We don’t feel good at calming down.

These are all low-hanging fruit coping strategies, the easiest and most obvious things to try. If you haven’t tried them, you should; if you have tried them without results, you shouldn’t give up. But most of them are just variations on telling ourselves to calm down, and they are hardly a magic bullet. Although they work some of the time for easier cases, many people with anxiety disorders have had little luck with these strategies, and we probably wouldn’t have an anxiety epidemic if they were highly effective. By nature, we can’t easily think our way out of anxiety. It’s like telling a depressed person to “think positively” — if they could do that, they wouldn’t be depressed!

But what if you had professional help?

Never in the history of calming down has anyone ever calmed down by being told to calm down.

~ unknown

It’s as if people expected us to will it away. If only we had thought about being more positive! How silly of us.

How I learned to cope with chronic pain, Ettenberg (www.theguardian.com)

Can a psychologist help you think your way out of anxiety? The state of the evidence about cognitive behavioural therapy for anxiety

Professionals also hope that changing your thinking will lead to changes in mood and behaviour, and that’s what cognitive behavioural therapy (CBT) is all about. It’s the most common psychotherapeutic approach to the problem. It’s how most psychologists will try to help you “think your way out.”

Recent evidence suggests that its benefit for depression has been overestimated in the past,10 and may be minimal. For anxiety, CBT can include some strategies for anxiety that may be more effective11 — there’s more leverage — but the bottom line evidence is mixed. It seems to work fairly well in a primary care setting,12 and it seems to be great for kids,13 but the benefits are much less clear for older adults,14 and it’s quite underwhelming when there’s pain and strange symptoms involved.15 In other words, CBT is probably the least effective when it matters the most. 🙁

Overall I’d call the evidence promising, but not exactly settled science. As an excellent example of the deep, scary complexity, there’s fascinating evidence that CBT may fail to treat chronic pain in some people because they are too inflamed, not because the inflammation is directly painful, but because the inflammation modifies mental state and behaviour and that makes the pain harder to treat!16

There’s even decent evidence that cheaper iCBT is “here to stay.”17 iCBT is Internet-delivered CBT — isn’t that cute? So maybe you’re even getting less anxious right now, reading this charming and reassuring article. You should probably keep reading!

It’s easy to get optimistic looking at CBT in the abstract (the scientific evidence), but in my direct personal experience with several psychologists over the years… well, let’s just say not all CBT is created equal. And it ain’t cheap either (hence the obviously more accessible iCBT option). There’s a great range of quality and creativity in its application, with a great many things that can sabotage success. CBT probably gives you a better chance than winging it on your own, but it’s still a hard road. And its weakness tends to be an excessive emphasis on the thinking part — using conscious thought as leverage — which I cynically think is simply because that’s what is easiest to do in a therapy session.18

Thinking may be what gets us anxious in the first place, and it may be hard to fight fire with fire, hard to use calming thoughts to subdue or replace worried thoughts. Or, worse, worried thoughts may over time become embodied, so entrenched in our behaviour and biology that they are no longer just thoughts — and fresh attempts to think less worried thoughts may have little impact, especially at first.

Fighting, flighting, tending, and befriending

The famous fight-or-flight response is a biological response to acute stress, and is more common in anxious people but not synonymous with anxiety. Someone suffering from chronic and excessive feelings of worry, nervousness, or unease is not necessarily in a panic. The anxious person is more likely to spend more time in this mode, either because they actually face more threats, or because they perceive more threats than there actually are. But we can worry about threats without ever actually experiencing one. Or reacting as if there’s one. My own childhood was a textbook case of that.19

There are other ways to respond to acute stress. We aren’t limited to fighting and flighting. There is also the much less famous tend-and-befriend response, for instance, a different behavioural strategy in which threats are dealt with more socially: tending to children, or seeking out the safety of the group and befriending people.

Stress pushes us to perform, and so anxiety can be helpful — to a point, after which we get a bit messy.20 “Panic” is the breakdown of performance during extremes of arousal (acute stress reaction, AKA “shock”). And if that reaction is delayed/chronic after exposure to traumatic events? That’s PTSD.

All of these things are linked to anxiety, but do not necessarily go together.

Does stress wreck us?

Many people have heard of “adrenal fatigue” (or adrenal insufficiency, or adrenal dysfunction). It is supposedly caused by chronics stress and “burnout” of the adrenal glands. And yet it probably doesn’t exist.21

And yet we do know that post-traumatic stress disorder and childhood adversity are strong risk factors for developing chronic widespread pain.2223 So how does that work?

It’s a common assumption that stress and anxiety have biological consequences, like adrenal fatigue, that drive up the risk of pain later in life, but a 2015 study of 2000 Dutch citizens over six years “could not confirm” those biological consequences.24 Their data did affirm the link between having a rough time in life and chronic pain — people who struggle emotionally are definitely at risk of starting to hurt more — but this occurs independently of any obvious, measurable biological changes, like adrenal fatigue.

If the study results are reproduced by others, it’s kind of a big deal; it implies that there is some other mechanism by which stress makes us vulnerable to pain, and the authors suggest that “psychosocial factors play a role in triggering the development of this condition.” This could be as simple as just saying that stress is directly sensitizing, that it cause a long-term or even permanent increase in the sensitivity of our brain’s threat-o-meter. Or it could be much more complex: people who suffer severe stress are probably more likely to do poorly in their next phase of life, losing income, status, security, friendships and romances, which opens up many possible paths to illness and pain.25

Or the study might have gotten it wrong. 😉 What if the changes causes by stress just aren’t “obvious”? That seems likely: this research was at odds with a fairly large body of evidence that stress is indeed hard on the body in a variety of ways, just not adrenal fatigue, and perhaps not in “obvious” ways that would turn up years later.26

Anxiety has a biological signature (and it’s sneaky)

Many anxious people are not obviously anxious. Anxiety can be “sneaky.”

It’s a common human pattern to control and hide anxiety from others and from ourselves by minimizing its expression, and especially by embodying it — by getting more still and tight. The British “stiff upper lip” is common around the world, and the tip of an iceberg of physical stoicism.

When people dismiss anxiety as a factor in their health, it’s often because they don’t think of themselves as a “nervous person.” But that doesn’t rule out anxiety: we can be anxious without being prone to anxious. Anxiety can be a recent and sometimes surprisingly subtle development in life, at odds with a much older self-image.

The anxious state is heady. Without thinking, there is no anxiety. It’s a mental state, characterised by the persistence of ideas about problems and dangers. People who lose their ability to think clearly due to stroke report an “ignorance is bliss” state (see below). When we are anxious, we are “in our heads,” as opposed to being “in your body” or “comfortable in your skin.” The more acute the worry, the busier the mind becomes, your brain switching to to spin cycle, scanning more vigilantly for dangers — most of them imaginary.

But as heady as it is, anxiety is also physical. Whether it is obvious or not, anxiety involves a distinctive set of changes in behavior and biology.

Adrenalin and cortisol — the stress hormones — may flow too freely and for too long. Of course, this has many adverse effects, and constitutes a genuine medical hazard.27

And many of of us try to hide it. We clamp down on it, try to suffocate its expression. We use muscular tension, stillness, and a lack of breath — like a rabbit freezing to avoid predator detection — to try to manage the churning and sinking sensations in the belly that come with worry, to hide them from ourselves and our friends and family.

These processes are so physical and habitual that they are difficult or impossible to interrupt by force of will. Once it starts, most of us are doomed to a few hours of whirling thoughts, and the physical consequences: back pain or neck pain, a throbbing headache, or insomnia28 are all common embodiments of stress (but there’s much more).

Anxiety and language are closely related. When Lauren Marks had a stroke, she woke up days later in the hospital without her words… and without anxiety, either. Aphasia is a bizarre loss of language due to brain injury.

Lauren had no internal monologue, and a vocabulary of only about forty strangely random words, but rather than being panicked by this state of affairs, she was blissfully ignorant of all her problems, because she did not have labels for them anymore. She felt calm and content. She did not have the vocabulary to worry.

I couldn't have been any more peaceful and satisfied. … Some people lose their inner monologue and some people do not. I did. So I didn't have that little voice chiming in saying, ‘Oh, you're in a world of trouble, Miss Marks. You are in a world of trouble…’ I didn't receive that message.”

Listen to this brilliant short podcast about her case of aphasia: “You learn a lot about language when you lose it.” Fascinating! Now if only there was a way to harmlessly and temporarily induce aphasia!

Make it more difficult to worry

An anxious mind cannot exist in a relaxed body.

Edmund Jacobson, founder of progressive muscle relaxation and of biofeedback

You can treat anxiety by making it harder to remain anxious.

In practicing the martial art of aikido, you don’t throw a person with brute force, or even with clever leveraging (as in Judo) — you simply position yourself in such a way that your practice partner finds it difficult to keep his balance.

Similarly, in some postures it is difficult to keep your worry. For instance, it is almost impossible to worry intensely if you adopt a confident posture, draw your attention downward into your trunk, and restore vitality and movement and breath to the belly. If you “contradict” the physical patterns of anxious state.

This can be called “grounding.” A lack of grounding is the mind-body pattern at the heart of anxiety. You probably can’t “get over” anxiety without some kind of grounding.

Once you are grounded, you won’t necessarily stop worrying! However, it will be harder to worry, and logic and reason might start to have some influence again. Many other responses to anxiety become easier. Once you are grounded, maybe then you have a shot at outsmarting your anxiety.

But grounding comes first.

Efficient grounding when it counts

Some well-chosen, specific grounding exercises can be done in two minutes in the office washroom, right after that incredibly irritating meeting with your boss.

They can be done quickly in the middle of the night when you have insomnia and don’t have the will to do anything challenging. You don’t have to get up for an hour and do yoga, or run up and down the apartment building stairs.

Unfortunately, most people don’t know that grounding exercises can be this quick and relevant to a crisis — assuming they know what grounding is in the first place!

Grounding is associated with all those flaky eastern spiritual disciplines and calisthenics: yoga, taijiquan, qigong, meditation and so on. Most people treat these things as slow and preventative medicine for stress, instead of a source of efficient and curative responses to episodes of anxiety.

People who are devoted practitioners in the preventative spirit may get paralyzed when anxiety strikes, forgetting everything they ever learned about yoga. It’s easy enough to do calming and grounding exercises when you are already calm. The challenge is doing them when you are not!

To beat anxiety, you need to do efficient grounding exercises as a direct response to anxiety. An hour of yoga is not efficient. Neither is a run on the sea wall, or a game of squash, or sitting meditation.

What is?

Move happy moves

Posture and movement might be able to create and reinforce emotional states.29 And, if posture can change emotions, it’s no surprise that it might also change pain sensitivity — and there is science that suggests it can.30 So, here’s an easy science-y anxiety and pain relief tip: Stand tall! Bold posture. Or, as a mentor of mine liked to put it, “Tits up!” Or as Todd Hargove of Better Movement put it:

It is usually quite obvious to people that changing their thoughts might be a good way to change their mood. For example, people might try to combat sadness or depression by “thinking happy thoughts.” Another possible approach would be to “move happy moves.”

“Move happy moves.” What a fun phrase. What fun advice.

So, when you are anxious or depressed, try combatting simply by standing like a master and commander. Do it like a drama class exercise: make it big and silly, have fun with it. (Subtle is good, too — depending on the circumstances.) It’s certainly not guaranteed to work, but no harm in trying.

To pretend to be calm is to be calm, in a way.

Gillian Flynn, Gone Girl

Change the beat: the metronome trick

Anxiety often involves racing thoughts, which are even more obvious when you attempt a meditative exercise such as focus on your breathing. If you lie down in a quiet room and try to simply count to 100 in your head, you might notice that your natural counting pace is set to “ridiculously fast.” Counting out loud might help to slow you down a little, but your brain still wants to rush ahead. Sometimes it’s almost impossible to rein it in with willpower.

So use metronome to first match and then tame your mental tempo. (Thanks to smart phones, almost anyone can conveniently download a free metronome app — no need to actually go shopping for a metronome.) Basically, count to 100 several times, a little slower each time, using a metronome instead of willpower. By all means tap your foot or a finger or some other gesture as well. Make it musical. This is called “entrainment.”31

  1. Set the metronome to a pace that matches the speed your brain wants to go. Try 100 beats per minute, for example. The idea is not to fight your natural impulse. Go with it for at least a minute.
  2. Slow the metronome down: drop it 10 beats per minute lower, to 90bpm, and count to 90. (Notice that each step will take a minute if you do it this way. You could also keep counting to 100 at a slower and slower pace, but I like the symmetry of one-minute steps.)
  3. Now set the metronome to 80bpm and count to 80…
  4. And now 70bpm and count to 70…
  5. And so on…

Obviously you can fiddle with the variables here: for instance, you could take smaller steps, or spend longer at each tempo. But if you systematically match a slower and slower metronome pace, your racing thoughts are likely to stop racing. At least for a while.

Change the beat: box breathing

Here’s another way of “changing the beat,” a minor tip but a good one, which is handy for managing anxiety in public situations, when you need to calm yourself discreetly. When your mind and heart and breath are racing, it can be difficult to switch to a measured, slower, deeper breathing pattern. So find a box to put it in.

Look for a rectangle like the side of a building, or a doorway. It may help your focus to anchor the breathing pattern to something you can see. Each side of the box represents a breath in or out, or a pause: breath "up" the left side, hold across the top, breath down the right side, hold across the bottom, and so on.

Set a comfortable pace and depth, as long as it's at least a little bit more slow, regular, and deep.

Now that’s a door! Any old rectangle in your field of view will do.

Get a massage

Getting a massage isn’t exactly efficient or cheap, but it may be an extremely effective method of grounding and relaxation. Literally all non-human primates groom each other — “social grooming” — and this is clearly a behaviour used for stress management. It is a near certainty that humans can benefit from the same kind of interaction, and massage is basically just ritualized, formal social grooming, without the parasite eating. Or you could pay for a cuddling service. Yes, that’s a real thing these days. Or, ahem, certain other services. The common denominator here is touch.

There’s no denying that massage is pleasant — for most people — but its medical benefits are much less clear and proven than you might think. Myths about massage abound. For instance, massage does not flush lactic acid out of cells, or meaningfully increase circulation, or reduce inflammation. Maybe it reduces cortisol levels, but even that popular notion is far from proven, and there is actually evidence that it’s wrong.32 Even in the unlikely event that massage actually does reduce cortisol levels, the phsyiology of stress is much too complex to assume cortisol reduction is in itself a meaningful, good thing.33 There’s just too much going on.

While many benefits of massage are still disconcertingly uncertain and hotly debated (by some), there are two truly proven ones. Dr. Christopher Moyer explains that the only truly confirmed benefits of massage are its effects on mood (“affect”),34 specifically:

  1. massage reduces depression
  2. massage reduces anxiety

And more massage is probably even better. Dr. Moyer:

We made an interesting discovery concerning the effect of the treatment on state anxiety. When a series of massage therapy sessions was administered, the first session in the series provided significant reductions in anxiety, but the last session in the same series provided reductions that were almost twice as large. This pattern was consistent across every study we were able to examine, which strongly suggests that experience with massage therapy is an important predictor of its success, at least where anxiety is concerned. To put it another way, it is possible that the greatest benefits come about only when a person has learned how to receive massage therapy.

So this should be a no-brainer: getting a massage is a better idea than taking meds in almost every possible way. It’s probably not cheaper. But it’s definitely better.

The abdominal lift

Yoga, taiqi, qigong, meditation are all full of exercises that can be done individually with great effect, if one has a clear, specific goal such as “efficient grounding when freaked out.” Here is the single best example, in my opinion, effective for most people, most of the time:

The abdominal lift is a classic yogic exercise, best known as a longevity exercise for its stimulating effect on the internal organs. It is also a powerful abdominal strengthener (including the rarely exercised transversus abdominis), is vital for mastering many breathing techniques, and makes all other breathing exercises easier.

  1. Stand with your upper body supported on your knees.
  2. Take at least three, oxygenating deep breaths to prepare yourself for the first lift.
  3. When you feel you have oxygenated sufficiently, blow all of your air out. Completely flush your lungs, and then hold your breath.
  4. Suck your belly in hard against your spine. Particularly focus on your low belly, below the navel. Hold the position and your breath for several seconds (go as long as you can), and then relax the belly — before breathing again (if you try to breathe before relaxing, it can hurt a bit).
  5. Resume breathing.

One abdominal lift takes about one minute, and three of them is a good dose of grounding, although I recommend five for tough cases.

After an abdominal lift, the physiological pattern of anxiety has not just been disturbed but reversed, and now you are ready to “get over it.”

More examples

Other great examples of efficient grounding exercises from qigong include:

Lightning bolts. Leap into the air with a big breath, and as you come crashing and stamping down, blow out hard and flick your arms and hands straight downwards, as though throwing lightning bolts into the ground. Ten of these, followed by some stillness, is wonderfully grounding.

Crane Spreads Wings Stand with your feet together, hands folded across your chest, hunched over. Breathe in and “spread your wings” — not just spreading your arms, but leaning back a little as well, opening way up, chin high, a strong line of tension through the chest and the belly. Close up again. Repeat several times.

And it’s not just the eastern spiritual disciplines that can be mined for useful grounding exercises. The anxiety pattern can also be broken by exercises drawn from many western traditions, such as Reichian body work or cognitive therapy. Here are two more examples:

Mental Propaganda. Worrying is a mental rut. Cognitive therapy suggests building new pathways with specific, deliberate mental alternatives. Write down a positive set of thoughts that are a specific alternative to the worrying pattern. Read them out loud in your head five times. (Why is this a grounding exercise? Because your mind and body are one system. It doesn’t matter whether you change the anxiety pattern in the head or the body first, just so long as you change it.)

For example, I survived a bad, scary year — in the aftermath of a terrible accident my wife had — by constantly writing and re-reading a document I called, heartbreakingly, “some notes on dealing with despair.” It was basically a series of the most reassuring things I could think of: elaborate blessing counting. It was quite carefully crafted, and it reassured me to craft it. Simply working on it was as much a part of the self-therapy as re-reading it. The challenge of thinking about and expressing good and reassuring thoughts was quite helpful. There were many nights I don’t know how I could have gotten back to sleep without that exercise.

Round Breathing. Twenty-five fast, deep clear breaths, without pausing at the top or the bottom, can ground you more completely — bring you back into your body — than most people will feel after any amount of meditation. This is hyperventilation, yes, and you may feel dizzy and that’s fine. For much more information, see The Art of Bioenergetic Breathing.

The examples I’ve offered you here are the tip of the iceberg, but you now possess the essential principles: anything you can come up with that disrupts the mental and physical patterns of anxiety will make it difficult to stay there.

Change your environment (a.k.a. get away from assholes)

Before you diagnose yourself with depression or low self esteem, first make sure you are not, in fact, just surrounded by assholes.

not Freud or Gibson, but Notorious d.e.b. (@debihope), Jan 24, 2010 (see QuoteInvestigator.com

More formally stated, as psychologist Dr. James Coyne put it, “depression is actually often actually misdiagnosed IED (Inappropriate Environment Disorder).”35 This applies equally to anxiety, I have no doubt. For instance, we know that macaques with low social status are treated very harshly and it has measurable effects on their immune systems: they are inflamed, they get more infections.36 Fascinating. And clearly their problem is that they are just surrounded by asshole macacques.

This is the kind of thing I mean when I cautiously counsel people to do their best to solve problems in their lives as a very basic defense against both anxiety and pain. I would never want to minimize the seriousness of mood disorders, but sometimes what looks like a mood disorder really is “just” a disheartening, stressful situation — and many crappy situations can be changed, sooner or later. Not that it’s easy. In fact, it’s often dazzlingly difficult in the short term. Consider the tragic example of domestic violence: surrounded by one asshole in particular.

But the worse it is, the greater the need.

Nutritional supplements for anxiety: pre-biotics

The first human test of prebiotics — not the much more familiar probiotics — for anxiety and stress was conducted in 2015.37 The results were promising, and so they’ve been widely reported as good news.

Prebiotics are basically food for the bacteria in your guts, which have a strange-but-true relationship with your nervous system.3839

There are many caveats about this evidence, of course. A detailed analysis of the paper by Examine.com (ERD #6, April 2015) explains that it’s not clear that the observed effects are clinically relevant:

especially since only one out of the many emotion-related variables tested was affected by a prebiotic. Assuming that prebiotic fibers could be used to “treat” anxiety or depression is a premature conclusion.

Patient.co.uk sensibly notes the “bewildering array” of products available and concludes “there is much work to be done before specific clinical guidelines and recommendations can be made.” Understatement!

But we still have “promising,” and these products are likely extremely safe to experiment with in moderation.

Nutritional supplements for anxiety: curcumin

Curcumin is the active ingredient in the bright yellow southwest Indian spice, turmeric. Curcumin has a larger evidence base [Examine.com] than most other supplements, is considered very safe, and there are reasons to think it may be useful in the treatment of both anxiety and pain — making it a perfect supplement to bring up here.

For anxiety: A 2015 study of rats found that curcumin increases the synthesis of docosahexaenoic acid (DHA), which “is linked to the neuropathology of several cognitive disorders, including anxiety.”40 The increases in DHA were accompanied by decreased anxiety. Crucially, one human trial also concluded that “curcumin has a potential anti-anxiety effect.”41

For pain: In another 2015 study, “curcumin caused moderate to large reductions in pain” in 17 men with very sore leg muscles.42 It also helped some aspects of strength loss. The effect size here passes the “impress me” test. These results constitute the only really good science news about any kind of treatment for delayed onset muscle soreness — there is no other treatment for it but the passage of time. Now it just needs to be replicated! It’s completely unknown whether this effect, if it’s real, would have any effect on any other kind of pain, but it is possible.

Supplements generally have a shabby track record, and I don’t recommend many of them.43 These shreds of evidence for curcumin are promising but definitely preliminary. They are probably not sufficient for most patients to justify the cost and hassle of supplementation. However, if you have anxiety and pain and you don’t mind the expense of a supplementation gamble, curcumin is about as good as it gets.

One minor complication drives up the cost and risk of wasting your money: plain curcumin is widely available, but unfortunately it’s poorly absorbed on its own. Most bottles advertise one method or another of enhancing absorption, and some of them use it to justify a much higher price point, but it’s hard to know (maybe impossible) how well any of them actually work. Just be aware that straight curcumin may not be effective.

Consider quitting coffee

Caffeine is one of those rare pleasures in life that doesn’t seem to have much of a downside, and even has some clear benefits, mostly actual performance enhancement.44 It doesn’t even matter how much of it you drink normally: you’ll get a boost from it whether you guzzle the stuff every day, or never touch it.45 And caffeine doesn’t dehydrate you. That’s a silly myth.46

So, for most people, caffeine is just a good thing. Sadly, people suffering from pain and/or anxiety may be exceptions. And, ironically, this may be true even though caffeine is also a mild pain-killer!47

It’s all about context and the difference between use and abuse. There’s a huge difference between a healthy athlete downing a Redbull half an hour before competition and an exhausted workaholic slamming back their third grande Americano of the day at 7pm.

Caffeine makes us hyper, and that can be somewhat exhausting. We pump more adrenalin, wear ourselves out, and lose sleep: risk factors for pain. Chronic, excessive caffeine abuse — perhaps a vicious cycle of self-medication, caffeine every morning, alcohol every night? — is likely to be an aggravating factor for anxiety and chronic pain. People in chronic pain are often already anxious and sensitized; regardless of why, artificial stimulation may be the last thing they need.

Casting coffee as a villain is pure speculation and seems to fly in the face of the hard evidence that it’s actually a performance aid, but actually there’s no conflict between what we know about the short term positive effects and what I fear about the long term effects. It can be “all of the above”! Caffeine can be good for pain in the short term and bad for it in the long term. (Booze has similar issues.48)

Bottom line: caffeine is a known mild analgesic and ergogenic aid, but caffeine abuse — which is probably anything from “common” to “practically universal,” depending on how you define it — is a plausible risk factor for chronic pain. Reader Kira Stoops sent me this interesting anecdote about her experience with quitting caffeine:

This is just one person’s story, but I feel quitting my morning Americano had a huge effect on my chronic pain. I’m not sure it’s so much the Americano but the chain of events…

I’ll start by saying I was prescribed Adderal, not for ADD, but because chronic pain turned me into a slug. I took one pill, the smallest dose, and shot through the roof. It was an uncomfortable amount of energy, and I started crying when it kicked in. To me, that was a sign my nervous system was already stimulated plenty, and I needed to start finding ways to wind it down more.

I’ve been drinking coffee since age 14, and figured my one-shot Americano habit was actually a healthy routine: I had to leave the house to get it, it created some social connection in the coffee shop, and the little jolt of caffeine gave me energy for the day.

Quitting was hard. But I started sleeping better right away. Many fibromyalgia patients have disturbed 4th wave sleep, and I think cutting out coffee-caffeine allowed me to sleep more deeply, and get more sleep in a shorter period of time. With more sleep, I had more clarity. Being off coffee gave me a good barometer for what my actual energy and anxiety levels were, once it was out of my system. Being able to “hear” what my body was trying to tell me helped too, so I could respond better.

I’d been plateaued at the same level of pain and exhaustion for about 6 months. Within a month of quitting caffeine, I was sleeping better, having energy longer, feeling more clear, taking on more work projects, hanging out with friends more, attending more events, and just generally finally seeing the needle move. All of these things had their own pain-lowering, positive effects. I’m still in pain (in a flare right this second) but I credit quitting that cup of coffee as the tipping point towards something better.

I just cut my afternoon green tea a few days ago, and will soon start reducing the two cups of black tea I drink daily.

I don’t think it’s for everyone. But my pain seems to come from clenching and tension, and my nervous system seems stimulated enough already. Letting coffee go helps me relax a little more. Plus, not having the morning habit forced me into even healthier morning habits. I would not have said coffee was a problem for me before. I didn’t feel especially stressed or anything by it. I thought it was a good routine. But I’m really glad I gave quitting it a shot.

And how’s it going now? Kira’s update several months later:

These cold cloudy days had me reaching for the brew…within a week of half-caf Americanos I was sleeping like crap, and within about 10 days my pain was steadily and unmistakably worse. Quit again a few days ago and started sleeping harder by the third night. Seems silly for a half-caffeine shot of espresso, but…sensitive nervous systems are just that, I guess.

It’s so delicious I miss it terribly, but less pain is worth the sacrifice.


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

Eleven updates have been logged for this article since publication (2006). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets PainScience.com apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.

I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

DecemberNew section: “Does stress wreck us?”

NovemberNew section: “Consider quitting coffee.”

SeptemberNew section: “Fighting, flighting, tending, and befriending.” And significant revision of another: “Anxiety has a biological signature (and it’s sneaky).”

JuneAdded an sidebar about the absence of anxiety in aphasia patients — not useful, but fascinating.

MarchAdded another important example of a possible medical cause of anxiety (positional cervical cord compression).

FebruaryNew section: “Change your environment (a.k.a. get away from assholes).” Added a fascinating citation to the cognitive behavioural therapy section.

JanuaryA significant infusion of the science of cognitive behavioural therapy, with several related clarifications and elaborations.

2016Revision of the first three sections: more careful use of terminology, more clarity about what this article is about, and more nuance about the idea that it’s hard to “outsmart” anxiety. Added an important citation about insomnia as a risk factor for anxiety.

2016Added a more formal and complete definition of anxiety to the introduction.

2016Added connection between anxiety and inflammation to the introduction.

2016Added footnote about the discovery of GABA-eating gut bacteria.

2006Publication.

Notes

  1. Shahidi B, Curran-Everett D, Maluf KS. Psychosocial, Physical, and Neurophysiological Risk Factors for Chronic Neck Pain: A Prospective Inception Cohort Study. J Pain. 2015 Dec;16(12):1288–99. PubMed #26400680.

    In 2012, Paksaichol et al convincingly concluded that there was still an absence of evidence that neck pain is caused by any psychological factor. Three years later, this study was published: the first direct and reasonably high quality evidence that depression does cause neck pain. It is not perfect — it’s not a very powerful experiment (a bit small) — but at least it was the right type of study, looking at the right things. 171 healthy office workers were quizzed for a year, identifying three risk factors: depression, poor neck muscle endurance, and low pain tolerance.

    Depression isn’t anxiety, of course, but there’s a lot of overlap between the two.

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  2. Science says the broader your smile and the deeper the creases around your eyes when you grin, the longer you are likely to live. Doubtless the opposite is also true: frowning and its associated moods are almost certainly harmful over time, by many mechanisms, such as insomnia. Chronic insomnia is known to be painful. BACK TO TEXT
  3. There’s the obvious stuff: insomnia, fatigue, mental fog, irritability, pain, sweating, nausea, diarrhea. But it gets weirder and worse: would you believe tingling and numb face, hands, and feet? Icy cold sweaty feet? Rashes? Trembling and twitching? Dizziness and shortness of breath? And these things may come out of the blue, without any apparent connection to stress or panic. (“Free-floating” anxiety is common.) Sometimes it seems like there’s not much anxiety disorders can’t do to us, especially when complicated by sleep deprivation. BACK TO TEXT
  4. Prolonged chronic stress may contribute to metabolic syndrome (Gohil et al) by messing with the hormonal balance of the hypothalamic-pituitary-adrenal axis (HPA-axis). Metabolic syndrome in turn is strongly associated with a number of markers of systemic inflammation and musculoskeletal conditions, such as more overt examples like Frozen Shoulder Guide and less obvious ones like neck pain (Mäntyselkä 2010). Oversimplifying down to a few words (probably too much): chronic stress may be inflammatory. BACK TO TEXT
  5. Association, American Psychiatric (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. p. 222. BACK TO TEXT
  6. “If the causes of anxiety disorders are so varied, then an adequate approach to recovery needs to be too. It is the basic philosophy of this workbook that the most effective for treatment panic, phobias, or any other problem with anxiety is one that addresses the full range of factors contributing to these conditions. This type of approach can be called quote ‘comprehensive.’ It assumes that you can’t just give someone the ‘right’ medication and expect panic or generalized anxiety to go away.” Bourne EJ. The anxiety & phobia workbook. 5th ed. Oakland (CA): New Harbinger Publications; 2010. p. 162. BACK TO TEXT
  7. Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia as a risk factor for developing anxiety and depression. Sleep. 2007;30(7):873–880.

    The results of this large and well-conducted survey are “consistent with insomnia being a risk factor for the development of anxiety disorders.”

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  8. There are strong clues that “minor” irritation of the upper spinal cord may simulate stress, firing up the same branch of our nervous system that handles emergencies (sympathetic arousal, see Holman). This would mostly occur due in spines arthritic enough to deprive the spinal cord of a nice wide, stable vertebral canal to live in (cervical spondylitic myelopathy). Although CSM is old pathology news, a low-grade crazy-making effect is new and still uncertain. And yet it’s nicely consistent with the much firmer, recent discovery that the autonomic nervous system is very disturbed in the aftermath of major spinal cord injuries, causing organ failure (see Sezer, Hagen, Hou, Stein) — this fact has been historically overshadowed by paralysis. Dysautonomia has other causes too, but tends to be associated with neurological diseases. What’s interesting here is the accumulating evidence that dysautonomia can be cause by a mechanical disturbance of the spinal cord. BACK TO TEXT
  9. Holman AJ. Positional cervical spinal cord compression and fibromyalgia: a novel comorbidity with important diagnostic and treatment implications. J Pain. 2008 Jul;9(7):613–22. PubMed #18499527.

    This study found that 71% of fibromyalgia patients and 85% with chronic widespread pain showed position cervical spinal cord compression on MRI — basically, light pinching of their spinal cord during neck extension. And so “recognition of unsuspected, comorbid cervical cord compression may provide new insight into [fibromyalgia’s] variable presentation.” Hoo boy, no kidding it would.

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  10. Johnsen TJ, Friborg O. The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis. Psychological Bulletin. 2015 May. PubMed #25961373. BACK TO TEXT
  11. Like exposure therapy, which is relevant to the phobic anxieties, and not at all to other types of anxiety. An agoraphobic, for instance, can gradually increase exposure to what they fear with longer and longer expeditions out into the world. But what does a patient with pain-dominated anxiety do? Expose themselves to more pain? The usefulness of exposure therapy depends. BACK TO TEXT
  12. Twomey C, O'Reilly G, Byrne M. Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis. Fam Pract. 2015 Feb;32(1):3–15. PubMed #25248976. BACK TO TEXT
  13. Warwick H, Reardon T, Cooper P, et al. Complete recovery from anxiety disorders following Cognitive Behavior Therapy in children and adolescents: A meta-analysis. Clin Psychol Rev. 2016 Dec;52:77–91. PubMed #28040627. BACK TO TEXT
  14. Hall J, Kellett S, Berrios R, Bains MK, Scott S. Efficacy of Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Older Adults: Systematic Review, Meta-Analysis, and Meta-Regression. Am J Geriatr Psychiatry. 2016 Nov;24(11):1063–1073. PubMed #27687212. BACK TO TEXT
  15. van Dessel N, den Boeft M, van der Wouden JC, et al. Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Syst Rev. 2014 Nov;(11):CD011142. PubMed #25362239.

    This metanalysis of trials of non-drug treatments for somatoform disorders and medically unexplained symptoms (which are closely related to anxiety disorders). It’s mostly about cognitive behavioural therapy, and it largely damns CBT with faint praise. Although “CBT reduced somatic symptoms” compared to doing nothing, the benefits were small and highly variable, as measured in too few studies of only low to moderate quality.

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  16. Lasselin J, Kemani MK, Kanstrup M, et al. Low-grade inflammation may moderate the effect of behavioral treatment for chronic pain in adults. J Behav Med. 2016 Oct;39(5):916–24. PubMed #27469518. PainSci #53548.

    Forty-one patients with chronic pain (at least six months, many much longer) were tested for signs of systemic inflammation. They all had stable medications, and no major complications. Then they were provided with two kinds of behavioural treatments for several weeks, measuring their progress in several ways.

    Unfortunately, no one did well: “No substantial overall effect of behavioral treatment on pain intensity and pain-related variables was found in the present study.” So that’s a sad result for these behavioural therapies.

    However, there is a scrap of backwards good news here: the patients with more inflammation “were more resistant to the improvement in pain intensity and in psychological variables contributing to pain.” Note that the mechanism of that effect is probably not that inflammation directly makes pain harder to treat, but actually modifies mental state and behaviour and that makes the pain harder to treat.

    The authors believe that this data tentatively “suggests that the inflammatory state may be one of the mechanisms of the persisting behavioral alterations in patients who do not respond to treatment, corresponding to previous studies on treatment resistant depression.”

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  17. Andrews G, Newby JM, Williams AD. Internet-delivered cognitive behavior therapy for anxiety disorders is here to stay. Curr Psychiatry Rep. 2015 Jan;17(1):533. PubMed #25413639. BACK TO TEXT
  18. For instance, in one of my most direct experiences with real-world CBT, the therapist labelled her work as “CBT” but was completely fixated on just talking about my personal history, like a classic psychoanalyst. When gently challenged, it became clear that she had only hand-wavey explanations for how this constituted CBT, and there was no end in site: she was going to indefinitely take my money while listening (expertly I’m sure!) to me talk about my past. “CBT” for $180/hour, ladies and gentlemen! BACK TO TEXT
  19. I was small and definitely at risk of being bullied, but I was also very good at avoiding it and rarely faced a real threat. So I worried plenty, but in my entire childhood only faced a violent situation a couple times — less than some people who never worried about it! BACK TO TEXT
  20. This relationship is formally described by the Yerkes-Dodson law, which states that performance initially increases with physiological or mental arousal, but then starts to degrade for most tasks. BACK TO TEXT
  21. Cadegiani FA, Kater CE. Adrenal fatigue does not exist: a systematic review. BMC Endocr Disord. 2016 Aug;16(1):48. PubMed #27557747. PainSci #52878.

    Conclusion:

    To our knowledge, this is the first systematic review made by endocrinologists to examine a possible correlation between the HPA axis and a purported “adrenal fatigue” and other conditions associated with fatigue, exhaustion or burnout. So far, there is no proof or demonstration of the existence of “AF”. While a significant number of the reported studies showed differences between the healthy and fatigued groups, important methodological issues and confounding factors were apparent. [Translation: biased, sloppy science! ~ Paul] Two concluding remarks emerge from this systematic review: (1) the results of previous studies were contradictory using all the methods for assessing fatigue and the HPA axis, and (2) the most appropriate methods to assess the HPA axis were not used to evaluate fatigue. Therefore, “AF” requires further investigation by those who claim for its existence.

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  22. Burke NN, Finn DP, McGuire BE, Roche M. Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical and preclinical evidence and neurobiological mechanisms. J Neurosci Res. 2016 Jul. PubMed #27402412. BACK TO TEXT
  23. Coppens E, Van Wambeke P, Morlion B, et al. Prevalence and impact of childhood adversities and post-traumatic stress disorder in women with fibromyalgia and chronic widespread pain. Eur J Pain. 2017 May. PubMed #28543929. BACK TO TEXT
  24. Generaal E, Vogelzangs N, Macfarlane GJ, et al. Biological stress systems, adverse life events and the onset of chronic multisite musculoskeletal pain: a 6-year cohort study. Ann Rheum Dis. 2015 Apr. PubMed #25902791. BACK TO TEXT
  25. Maté G. When the body says no: the cost of hidden stress. Alfred A. Knopf Canada; 2003. With clarity and passion, Vancouver physician Gabor Maté tells the stories of people whose pain and illnesses emerged from lives filled with stress, anxiety and depression, illuminating the next frontier in medicine: the elusive mind-body connection. BACK TO TEXT
  26. Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed ed. New York: Times Books; 2004. In contrast to Gabor Maté’s book, just cited, which is much more about way that stress and illness gets all tangled up, psychologist Robert Sapolsky’s book explores the biology of stress in great detail — especially the way chronic stress is fundamentally at odds with health. BACK TO TEXT
  27. Kakiashvili T, Leszek J, Rutkowski K. The medical perspective on burnout. Int J Occup Med Environ Health. 2013 Jun;26(3):401–12. PubMed #24018996.
    Burnout was found to be a risk factor for myocardial infarction and coronary heart disease. It was also related to reduced fibrinolytic capacity, decreased capacity to cope with stress and hypothalamic-pituitary-adrenal (HPA) axis hypoactivity. Severe burnout symptoms are associated with a lower level or smaller increase of the cortisol awakening response (CAR), higher dehydroepiandrosterone-sulphate (DHEAS) levels, lower cortisol/DHEAS ratios and stronger suppression as measured by the dexamethasone suppression test (DST). More and more literature works suggest that the evaluation of the HPA axis should be brought to the attention of primary care physicians.… Chronic stress-related disorders often fall outside the category of a true disease and are often treated as depression or not treated at all.
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  28. Knutson KL, Van Cauter E, Rathouz PJ, et al. Association Between Sleep and Blood Pressure in Midlife: The CARDIA Sleep Study. Arch Intern Med. 2009 Jun 18;169(11):1055–1061. PubMed #19506175. PainSci #55440.

    Bad sleeps — quantity and quality, probably especially if caused by stress — are associated with elevated blood pressure, according to a side project of the big CARDIA study of coronary artery disease. They used wrist gadgets to monitor sleep and blood pressure in more than 500 adults in their 30s and 40s. The authors say the sleep-BP link is supported by previous research and “laboratory evidence of increased sympathetic nervous activity as a likely mechanism underlying the increase in BP after sleep loss.”

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  29. Carney DR, Cuddy AJ, Yap AJ. Power posing: brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychol Sci. 2010 Oct;21(10):1363–8. PubMed #20855902.

    This experiment supposedly shows that adopting a “powerful” (confident) pose changes people’s hormonal levels and increases their willingness to take risks as if they actually had more power. “A person can, by assuming two simple 1-min poses, embody power and instantly become more powerful.” This is plausible and interesting, but melodramatically stated, and probably over-stated. There’s a very popular TED talk about this paper, and so (unsurprisingly) the authors have been accused of reaching beyond what their data can support:

    So, take this idea with a grain of salt.

    See also Bohns, which presents evidence that power postures can also reduce pain sensitivity.

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  30. Bohns V, Wiltermuth S. It hurts when I do this (or you do that): Posture and pain tolerance. Journal of Experimental Social Psychology. 2012 Jan;48(1):341–345. PainSci #54508. BACK TO TEXT
  31. Entrainment refers to a bunch of this, but in the context of “biomusiscology”: internal synchronization to an external rhythm. The science of why a fun tune gets our heads nodding or feet tapping. BACK TO TEXT
  32. I discuss the myths of massage in great detail in Does Massage Therapy Work? BACK TO TEXT
  33. Cortisol levels after a massage do not give a meaningful picture of the organism, and there is no direct relationship between a temporary cortisol reduction and any health benefit. What matters is cortisol levels over time, but even that isn’t exactly straightforward: stress and cortisol have a complex and chaotic relationship regulated by many variables out of our control. BACK TO TEXT
  34. Moyer CA. Affective massage therapy. Int J Ther Massage Bodywork. 2008;1(2):3–5. PubMed #21589715. PainSci #54758.

    Dr. Christopher Moyer explains that the only confirmed benefits of massage are its effects on mood (“affect”), specifically depression and anxiety. “Together, these effects on anxiety and depression are the most well-established effects in the MT research literature. They are especially important for us to understand not only for their own sake, but also because anxiety and depression exacerbate many other specific health problem.” He proposes that “the time is right to name a new subfield for massage therapy research and practice: affective massage therapy.”

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  35. Not a real thing: a whimsical, imaginary diagnosis. But not entirely silly either. Maybe there should be such a diagnosis. BACK TO TEXT
  36. Snyder-Mackler N, Sanz J, Kohn JN, et al. Social status alters immune regulation and response to infection in macaques. Science. 2016 Nov;354(6315):1041–1045. PubMed #27885030. BACK TO TEXT
  37. Schmidt K, Cowen PJ, Harmer CJ, et al. Prebiotic intake reduces the waking cortisol response and alters emotional bias in healthy volunteers. Psychopharmacology (Berl). 2015 May;232(10):1793–801. PubMed #25449699. PainSci #54164. In the test, the prebiotic product Bimuno®-galactooligosaccharides (B-GOS) appeared to be effective (while another product did not). Specifically, “The salivary cortisol awakening response was significantly lower after B-GOS intake compared with placebo. Participants also showed decreased attentional vigilance to negative versus positive information in a dot-probe task after B-GOS compared to placebo intake.” But caution: please note that this product is one of a class of sugars that may cause bowel irritation. If you experiment with it, do be alert for symptoms of irritable bowel syndrome. BACK TO TEXT
  38. Schmidt et al: “There is now compelling evidence for a link between enteric microbiota and brain function.” Strange but true. Wikipedia: “The gut–brain axis refers to the biochemical signaling taking place between the gastrointestinal tract and the nervous system, often involving intestinal microbiota, which have been shown to play an important role in healthy brain function.” BACK TO TEXT
  39. Speaking of things bacteria eat: in 2016, scientists discovered a species of gut bacteria that has a GABA-only diet. Gamma-Aminobutyric acid is an important neurotransmitter which has a critical role in keeping our cool, which is an understatement: it’s the most widely used inhibitory neurotransmitter in human physiology, the body’s own tranquilizer. Drugs like Valium (the most famous of the benzodiazepenes) work by enhacing GABA’s effects. The discovery of a gut bacteria that feeds exclusively on GABA may be one the first clear, direct explanations of the “gut-brain connection,” of how the contents of the poop chute can affect moods. An overpopulation of these wee beasties could potentially suppress GABA levels…which would be bad. Intriguing stuff. BACK TO TEXT
  40. Wu A, Noble EE, Tyagi E, et al. Curcumin boosts DHA in the brain: Implications for the prevention of anxiety disorders. Biochim Biophys Acta. 2015 May;1852(5):951–61. PubMed #25550171. BACK TO TEXT
  41. Esmaily H, Sahebkar A, Iranshahi M, et al. An investigation of the effects of curcumin on anxiety and depression in obese individuals: A randomized controlled trial. Chin J Integr Med. 2015 May;21(5):332–8. PubMed #25776839. BACK TO TEXT
  42. Nicol LM, Rowlands DS, Fazakerly R, Kellett J. Curcumin supplementation likely attenuates delayed onset muscle soreness (DOMS). Eur J Appl Physiol. 2015 Mar. PubMed #25795285. BACK TO TEXT
  43. PS Ingraham. Can Supplements Help Arthritis and Other Aches and Pains? Debunkery and analysis of supplements and food-like medicines (nutraceuticals), especially glucosamine, chondroitin, and creatine, mostly as they relate to pain. PainScience.com. 7315 words. BACK TO TEXT
  44. Hogervorst E, Bandelow S, Schmitt J, et al. Caffeine Improves Physical and Cognitive Performance during Exhaustive Exercise. Medicine & Science in Sports & Exercise. 2008 Oct;40(10):1841–1851. PainSci #56104. Caffeine will “significantly improve” not only endurance performance, but “complex cognitive ability during and after exercise.” The researchers studied 24 well-trained cyclists, giving them either 100mg of caffeine or a placebo and then testing their endurance and their mental function during and after workouts. The signal was loud and clear: caffeine consumption boosted their performance. BACK TO TEXT
  45. Gonçalves Ld, Painelli Vd, Yamaguchi G, et al. Dispelling the myth that habitual caffeine consumption influences the performance response to acute caffeine supplementation. J Appl Physiol (1985). 2017 May:jap.00260.2017. PubMed #28495846.

    This trial demonstrated that caffeine supplementation boosts athletic performance even if you are used to its effects. Forty endurance cyclists were divided into groups of low, moderate, and highly daily caffeine intake. They all did three cycling tests after drinking caffeine, a placebo, or nothing at all. Performance on caffeine was clearly best across the board for all participants, regardless of typical caffeine intake.

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  46. Killer SC, Blannin AK, Jeukendrup AE. No evidence of dehydration with moderate daily coffee intake: a counterbalanced cross-over study in a free-living population. PLoS One. 2014;9(1):e84154. PubMed #24416202. PainSci #53892.

    Many people believe that coffee is dehydrating. To test this popular idea, 50 men drank four cups (200ml) of either coffee or water each day for three days while their diet and activity were controlled. There were no differences in their body mass, urine volume, and signs of hydration in the blood and urine (pee clarity, basically). If you can drink almost a litre of coffee a day and have no measurable effect on hydration, then it is not “dehydrating” to any meaningful degree. The authors reasonably concluded that coffee “provides similar hydrating qualities to water.”

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  47. Derry CJ, Derry S, Moore RA. Caffeine as an analgesic adjuvant for acute pain in adults. Cochrane Database Syst Rev. 2014 Dec;(12):CD009281. PubMed #25502052. “The addition of caffeine (≥ 100 mg) to a standard dose of commonly used analgesics provides a small but important increase in the proportion of participants who experience a good level of pain relief.” BACK TO TEXT
  48. We can draw a strong analogy to alcohol, which definitely relieves pain in a meaningful way ... for as long as you’re drunk! It’s the original anaesthetic. But at the same time, we know with extremely high confidence that the stuff is a nasty poison and downright terrible for you when habitually abused long term.) BACK TO TEXT