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-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.
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 many people. Exercise is definitely 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. In fact, there are at least several insidious or underestimated medical causes of anxiety, which may explain an awful lot of allegedly “free floating” anxiety and symptoms of anxiety disorder in people who do not seem like a good psychological fit for it.
Low serotonin, caused by a genetic defect, is one of the most recently discovered examples.7 The neurotransmitter serotonin is used everywhere in biology, and the glitchy gene causes chronic shortages with complex effects, including amplified bodily sensations, which is basically nightmare fuel.8 These patients are so notorious for their bizarre panoply of symptoms that they are routinely written off as anxious, “difficult” hypochondriacs… which they probably are, but not for psychological reasons! Does this sound like you? Take the somatic awareness quiz. And how common is this gene? At ten percent of the population, it’s about five times more common than red hair. Ten percent! Read more.
Insomnia is another classic example: it’s major risk factor for anxiety disorders,9 so anything that interferes with sleep — practical or pathological — is obviously an important consideration. And of course anxiety is a risk factor for insomnia! The effects of anxiety/stress are relieved by sleep, but also make it harder, and failing at sleep will cause more stress. It’s always harder to treat either insomnia or anxiety without treating the other.
Chronic pain is extremely common, and can be both a 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.
Spinal cord irritation is a particularly disturbing example, 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.10 This is called “dysautonomia.” Even minor positional cervical cord compression may cause clinically significant dysautonomia, and even just a little bit of it seems to be potent. It’s been found that many people with fibromyalgia (unexplained chronic widespread pain) also have erratic spinal cord compression,11 which has profound implications: fibromyalgia might not only associated with stress, but also with “artificial” stress brought on by a mechanical spinal cord irritation. Which is not actually all that rare, believe it or not.12 And for every case with a clear clinical presentation, there may be many that are rather vague. It’s a bit sinister, isn’t it?
Maybe you’re anxious, or maybe you just have a slightly irritated spinal cord.
And then there are a bunch of other causes of dysautonomia as well, most of them individually rare, but collectively it’s not exactly an exotic medical phenomenon.
Imagine for a moment the absurdity and futility of spending thousands on counselling to try to learn to be less anxious when your anxiety has a simple-in-principle medical cause like this. Ugh.
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)
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, or telling ourselves, can be 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. Here are some of the typical ways that people reflexively try to calm down (AKA “cope with anxiety”):
- We tell ourselves to “get over it,” and that really doesn’t work. (But it can.)
- We apply logic and reason, telling ourselves that it doesn’t make sense to be so anxious, and that doesn’t work either. (But sometimes it does.)
- We seek out the logic and reason of others, of friends with perspective and experts with authority, and that usually doesn’t work. We still worry, we still feel jittery. (But, again, sometimes it works.)
- We try to distract ourselves, and sometimes that sort of works — but only temporarily.
- We try to sweat it out with exercise, and that may be the best solution that many people use. But it can still be unsatisfying. It takes a good chunk of time and energy, it doesn’t always work, and you can’t exercise all the time.
These aren’t “best practices,” just the easiest and most obvious things that worried people tend to try. That doesn’t mean they are useless, and if you haven’t tried them, you should.
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 there are are other, better ways to calm down. And what if you had professional help with that?
Never in the history of calming down has anyone ever calmed down by being told to calm down.
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
Cognitive behavioural therapy (CBT) [Wikipedia] is a dominant force in psychotherapy and the most common treatment approach for anxiety. It’s how most psychologists will try to help you “think your way out.” And behave your way out.
CBT is widely considered to be a proven therapy for anxiety, and some specific types have especially firm foundations.13 It seems to work fairly well in a primary care setting,14 and it seems to be great for kids.15 But the benefits compared to placebo are underwhelming, and a technically positive 2018 review showed results that were less than impressive, and concluded that “better treatments are needed.”16 The benefits are especially less clear for older adults,17 and it’s definitely underwhelming when there’s pain and strange symptoms involved.18 In other words,
Overall I’d call the evidence for CBT “promising,” but far from settled science or remotely proven. 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.19 That’s a deep rabbit hole there.
There’s some decent evidence that cheaper iCBT is “here to stay.”20 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.
Theory vs practice: you’re not always going to get ideal CBT
It’s easy enough to get optimistic about CBT in the abstract, but in my personal experience with several psychologists over the years, and based on a lot of communication with readers … well, let’s just say not all CBT is created equal. There’s a great range of quality and creativity in its application, a big gap between the best possible CBT and the kind that many people will actually encounter in “the wild” — being sold for a bare minimum of $100/hour. (Which is why a more accessible iCBT option is intriguing.)
Good CBT probably gives you a better chance than winging it on your own, but it’s still not an easy road. And its most common weakness in practice seems to be an unfortunate overemphasis on the thinking part — using conscious thought as leverage. Which I cynically assume is an issue simply because that’s what is easiest to do in a therapy session.21
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 really 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.22
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.23 “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?
The brain has a vast potential for sticking its nose into the immune system’s business.
~ Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004, p. 144
Many people have heard of “adrenal fatigue.” It is supposedly caused by chronic stress and “burnout” of the adrenal glands. And yet it probably doesn’t exist.24 (“Adrenal insufficiency” is a real disease with several medical causes — but not stress.)
It’s a common assumption that stress and anxiety have biological consequences that drive up the risk of pain later in life, and there is evidence to support that.27 Another good possibility is that chronic stress ramps up immune function to the point of dysfunction.28
“A schematic representation of how repeated stress increases the risk of autoimmune disease,” adapted from Sapolsky’s Why Zebras Don’t Get Ulcers.
That said, Sapolsky also makes it clear that we shouldn’t get carried away: stress isn’t such a villain that we can blame it for any health problem. He expresses deep contempt for how the idea of ruinous stress has been used to sell miracle cures, telling desperate people that they can recover from serious diseases like cancer with various psychological and stress-reduction hacks.29
And these biological consequences of stress are far from a sure/clear thing. For instance, a 2015 study of 2000 Dutch citizens over six years “could not confirm” them.30 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 — just not with any obvious stress-y biology.
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.” Maybe it’s just that stress is directly sensitizing, that it gives a lasting boost to the sensitivity of our brain’s threat-o-meter. Or it could be much more complex: for instance, 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.31
Or the study might have gotten it wrong. 😉 What if the changes caused 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.32
Stress and injury risk and poor injury recovery
Psychological stress is risk factor for injury — a great point to make when discussing anxiety on a website that is mainly about aches and pains! Todd Hargrove:
There is evidence that chronic emotional stress predicts injury.33343536 For example, athletes with preseason anxiety are more likely to get hurt. Stress after an injury predicts greater difficulty in return to play. These findings are especially notable in light of the inability of various biomechanical screening tests to accurately predict injury risk. Interestingly, subjective measures of stress level, which are obtained by simply asking an athlete about their readiness to train, are better reflections of actual training load than objective measures like hormone levels or markers of inflammation.
~ Todd Hargrove, Playing With Movement: How to explore the many dimensions of physical health and performance, 2019 p. 92, ch. 4: “Stress and Adaptation”
And stress and anxiety don’t just boost your injury risk, they also make it harder to recover from injury — which is where it really starts to get relevant to chronic pain. In many people, it’s hard to separate chronic pain from failed recovery from a list of past injuries.
If anxiety causes pain, does that mean the pain is “all in your head”?
Of course not. “Psychosocial factors” refers to the dizzying array of stresses in our lives, all the possible reasons we get anxious, which can also independently lead to pain in many ways (regardless of whether or not stress has a clear biological signature).
So, is that just an elaborate way of saying the pain is “all in your head”? No — that phrase implies mental illness or faking it. What we’re talking about here is about stress/anxiety creating fertile ground for a crop of chronic pain. This may occur in so many ways that it’s impossible to say exactly how it happens, just like we can’t possibly know which climate factors lead to a specific storm.
Psychosocial factors in pain are a completely different thing from “all in your head.”
And yet, sadly, some health care professionals may not understand this, and some of them may equate psychosocial factors with mental illness and malingering — all the same thing in their heads. We know many healthcare professionals will take pain less seriously if there’s no obvious biological source of pain to treat, even when there is evidence of serious psychosocial factors.37 For instance, physiotherapists may stigmatize psychosocial factors in back pain, feel unprepared to deal with psychosocial factors, and prefer to grapple with the “more mechanical aspects” of back pain.38
Anxiety and thinking
The anxious state is very cerebral. 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 spin cycle, scanning more vigilantly for dangers — most of them imaginary.
Without thinking, there can be no chronic 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. When Lauren Marks had a stroke, she woke up days later in the hospital without her words — aphasia, a bizarre loss of language due to brain injury — and without anxiety, either. 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!
The biological signature of anxiety
If you couldn’t ask someone about their thoughts, how can you tell if they are anxious? As heady as it is, anxiety
It’s easy enough to detect with a blood test. All chronically stressed mammals have too many glucocorticoids — stress hormones — floating around. Of course, as already discussed, this probably has many adverse effects, and constitutes a medical hazard, including a risk of more pain.39
The behavioural signature of anxiety (stiff upper lip syndrome)
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.
Because of the stigma against anxiety, most of us try to hide it. Everyone’s strategies are different, but it’s common to just get less expressive and stiff in general, a physical stoicism. The British “stiff upper lip” is a common strategy for concealing anxiety (and any other emotional vulnerability). But it won’t fool anyone experienced.
Psychosomatic disorders are physical symptoms that mask emotional distress. The very nature of the physical presentation of the symptoms hides the distress at its root, so it is natural that those affected will automatically seek a medical disease to explain their suffering.
~ It's All in Your Head, by Suzanne O'Sullivan, 8
And we use muscular tension, stillness, and a lack of breath — like a rabbit freezing to hide from a predator — 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. Of course no everyone shows anxiety this way, but it’s extremely common.
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 insomnia40 are all common embodiments of stress (but there’s much more).
Social isolation and loneliness
Just a quick word about this: being lonely is one common (epidemic?) way to be anxious and stressed.
Social isolation is a major general health suppressor in the same league as other major vulnerabilities like sleep deprivation or smoking.41 It almost certainly often involves increased vulnerability to chronic pain as part of the deal.42 We do know that sensitization and pain chronicity are driven by catastrophization and social factors, and injury and disability are going to seem more threatening — more “catastrophic” — to people without good social support, all other things being equal.
In other words, you have more to worry about when you’re lonely. It’s a significant general anxiety booster.
Efficient calming when it counts
In our privileged lives, we are uniquely smart enough to have invented these stressors and uniquely foolish enough to have let them, too often, dominate our lives. Surely we have the potential to be uniquely wise enough to banish their stressful hold.
~ Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004, p. 408
Some well-chosen, specific calming 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 calming exercises can be this quick and relevant to a crisis.
Calming exercises are 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 directly relevant responses to episodes of anxiety. But they can be.
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 exercises when you are already calm. The challenge is doing them when you are not.
To beat anxiety, you need to do efficient calming 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 might be? I explore a bunch of possibilities in the rest of the article.
Make it more difficult to worry with confident posture and calm breathing
An anxious mind cannot exist in a relaxed body.
Edmund Jacobson, founder of progressive muscle relaxation and of biofeedback
You can try to treat anxiety indirectly by creating physical circumstances in which it’s harder to remain anxious.
In practicing the Japanese martial art of aikido, you don’t throw a person with brute force, or even with clever leveraging (as in judo). Instead, you position yourself in such a way that your practice partner finds it difficult to keep his balance. Similarly, in some positions it is harder to keep your worry.
Behaviours associated with calm and confidence will also blunt anxiety in the short term, like breathing slowly and deeply. Just like it’s hard to stay pissy while you’re making silly faces, it’s hard to stay anxious when you act confident in various ways. It’s basically an acting exercise that “contradicts” the typical physical patterns of anxious state. Act as if you are confident, focusing on specific things that are easy to fake. This gives you some leverage on your emotional state.
Sharp readers will notice that I’m basically talking about “power posing” — an extremely popular idea (one of the most popular TED talks of all time), and a bit sketchy. Years later, the evidence strongly suggests a confident posture alone is not a potent “active ingredient,” but it does still have measurable effects… and it works even better when you expect it to.43 So I think it’s more of a package deal, and anything you can do to inspire yourself to feel more confident is worth doing.
Acting confident is not an anxiety “cure” any more than taking a decongestant is a cure for the common cold, but it is probably a way to feel better in the short term. And while you’re feeling a little better, logic and reason might have some more influence. Maybe you’ll have a better shot at “outsmarting” your anxiety when it’s dialed down a notch or two.
Move happy moves
A little more complex than posture and breathing: the right kind of movement might also be able to create and reinforce emotional states. 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
Why is exercising helpful for stress? It simulates what stress is trying to prepare us for
As mentioned above, exercising for stress control is an option that isn’t fully satisfying to many people, and often awkward for people in pain. But it’s still one of the most accessible and effective options, and firmly grounded in biology and science. And there’s a simple and fascinating reason for this, which is well worth understanding: basically, exercise simulates a reaction to a stressful emergency which then also triggers the relaxation and recovery mode that follows. Robert Sapolsky:
The stress-response is about preparing your body for an explosive burst of energy consumption right now; psychological stress is about doing all the same things to your body for no physical reason whatsoever. Exercise finally provides your body with the outlet that it was preparing for.
~ Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 255
I think this is one of those really great little “user’s manual” things to understand about our own nature. The biology of stress is all about mobilizing biology resources for intense, life-saving activity, like running like hell from a predator, or (eek) fighting one. The curse of being human is that the same emergency biology can be triggered by abstract concerns, no predators required. But stress and anxiety are still preparing us for an emergency. So go with it — act like there’s an emergency!
Why would that help? Why would urgent action be relaxing in any way? Because it’s going with the flow, sticking to the biological script, getting it over with and moving on to the next part: recovery! Just as we are biologically programmed to prepare for perceived threats, we are also programmed to de-escalate the stress response after the excitement is over. The exercise simulates a “fight or flight” response, and when we “survive” the incident, it’s a clear signal: “stand down, emergency’s over, time for recovery!” So do what your body is expecting — sprint a block or two, or whatever intense activity your body can manage — and then ride the wave of post-exertional relaxation.
This is why exercise is an effective outlet for frustration, which is well-known to measurably reduce the stress-response.
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, breathe 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 than usual.
Now that’s a door! Any old rectangle in your field of view will do.
There’s a nice iPhone app dedicated to their breathing exercise: Box Breathe.
Taking your time on the exhalation
Breathing regularity and overall slowness is a good start, but extending exhalation is even better for a specific biological reason: exhalation is literally more relaxing than inhalation. That is how we are wired.
Whenever you inhale, you turn on the sympathetic nervous system slightly, minutely speeding up your heart. And when you exhale, the parasympathetic half turns on, activating your vagus nerve in order to slow things down (this is why many forms of meditation are built around extended exhalations).
~ Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004, p. 48.
You could make a simple change to the box breathing method described above: instead of holding after inhalation, you can distribute the breaths around the sides of the box like this: breathe in, breathe out, breathe out, hold it out.
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.”44
- 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.
- 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.)
- Now set the metronome to 80bpm and count to 80 …
- And now 70bpm and count to 70 …
- 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.
I would apply the 80/20 rule to stress management: 80 percent of the stress reduction is accomplished with the first 20 percent of effort.
~ Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 414
Get a massage
Getting a massage isn’t exactly efficient or cheap, but it may be an extremely effective method of 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:45 it does not flush lactic acid out of cells, or increase circulation,46 or reduce inflammation.47 Maybe it reduces cortisol levels, but even that popular notion is far from proven, and there is actually evidence that it’s wrong. 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.48 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”),49 specifically:
- massage reduces depression
- 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, t’ai chi, qigong, meditation are all full of exercises that can be done individually with good effect, if one has a clear, specific goal of calming down. Here is one of the best examples, in my opinion:
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.
- Stand with your upper body supported on your knees.
- Take at least three, oxygenating deep breaths to prepare yourself for the first lift.
- When you feel you have oxygenated sufficiently, blow all of your air out. Completely flush your lungs, and then hold your breath.
- 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).
- Resume breathing.
One abdominal lift takes about one minute, and three of them is a good dose of calming, 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.”
Other great examples of efficient grounding and calming 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 hard to stay anxious through.
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 calming 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 calm 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.
More formally stated, as psychologist Dr. James Coyne put it, “depression is actually often actually misdiagnosed IED (Inappropriate Environment Disorder).”50 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.51 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 2015.52 The results were promising, and so they’ve been widely reported as good news.
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.”55 The increases in DHA were accompanied by decreased anxiety. Crucially, one human trial also concluded that “curcumin has a potential anti-anxiety effect.”56
For pain: In another 2015 study, “curcumin caused moderate to large reductions in pain” in 17 men with very sore leg muscles.57 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.58 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.59 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.60 And caffeine doesn’t dehydrate you. That’s a silly myth.61
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.62
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.63)
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
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?
Nineteen 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.
July — Added another pathological cause of anxiety: high somatic awareness caused by hyposerotonemia (see Khoury et al).
May — Added information and citations about anxiety as a risk factor for injury. Finally cleaned up and modernized my muddled thoughts on the hiding of anxiety and its physical and biological signs.
January — New section, “Why is exercising helpful for stress? It simulates what stress is trying to prepare us for.”
2018 — Completely renovated the discussion of the effect of posture on mood and anxiety, especially upgrading the references substantially, after reading Gronau et al. My previous writing on this topic was dreadful, amateurish stuff leftover from the earliest days of this website — good riddance.
2018 — New section, “If anxiety causes pain, does that mean the pain is ‘all in your head’”? (Of course not.)
2018 — Revised and clarified medical causes of anxiety, plus several other minor edits.
2018 — Added sidebar debunking the over-hyped idea that “stress is your friend,” which came from a wildly popular TED talk.
2018 — Science update, based on Carpenter et al on the efficacy of cognitive behavioural therapy: “more effective treatments needed.”
2017 — New section: “Does stress wreck us?”
2017 — New section: “Consider quitting coffee.”
2017 — New section: “Fighting, flighting, tending, and befriending.” And significant revision of another: “Anxiety has a biological signature (and it’s sneaky).”
2017 — Added an sidebar about the absence of anxiety in aphasia patients — not useful, but fascinating.
2017 — Added another important example of a possible medical cause of anxiety (positional cervical cord compression).
2017 — New section: “Change your environment (a.k.a. get away from assholes).” Added a fascinating citation to the cognitive behavioural therapy section.
2017 — A significant infusion of the science of cognitive behavioural therapy, with several related clarifications and elaborations.
2016 — Revision 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.
2016 — Added a more formal and complete definition of anxiety to the introduction.
2016 — Added connection between anxiety and inflammation to the introduction.
2016 — Added footnote about the discovery of GABA-eating gut bacteria.
2006 — Publication.
- 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. There’s a lot of overlap between depression and practically everything, because it’s “the common cold of psychopathology” (Why Zebras Don’t Get Ulcers p. 271). Really I think anxiety should be included in that analogy. Anxiety and depression are the cold/flu of psychopathology.BACK TO TEXT
- 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
- 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
- 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
- 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
- “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
- Khoury S, Piltonen MH, Ton AT, et al. A functional substitution in the L-aromatic amino acid decarboxylase enzyme worsens somatic symptoms via a serotonergic pathway. Ann Neurol. 2019 Jun. PubMed #31177555. ❐
This study strongly linked systemic sensory sensitization — not just pain, but all kinds of body sensations — to a glitchy gene that causes low levels of serotonin in 90 chronic pain patients. Uncomfortable awareness of all kinds of sensation is a well-known but previously unexplained companion of chronic widespread pain, but most healthcare professionals have assumed that it is driven by psychological hypervigilance and is prominent feature of the so-called “fibromyalgia personality.” This research tells a different story: a clear correlation with a genetic malfunction of an enzyme, which significantly slows down production of the neurotransmitter serotonin.
For a much more detailed exploration of these results, see A genetic defect that exaggerates all sensations (including pain).BACK TO TEXT
- In a negative context only. For a person who is safe and happy, the extra sensation is probably innocuous. Likely their sensory life just feels a little more rich and full! But if challenged by a mysterious illness or a difficult injury rehab, every sensation becomes a potential symptom, clue, and threat — which is a great formula for anxiety and pain. BACK TO TEXT
- 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.”BACK TO TEXT
- 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
- 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.BACK TO TEXT
- Acute “cervical spondylitic myelopathy” isn’t common, but it’s not exactly rare either. It occurs in about 5 to 10 percent of patients who have symptomatic spondylosis, which is fairly common. BACK TO TEXT
- 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
- 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
- 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
- Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depress Anxiety. 2018 Feb. PubMed #29451967. ❐ BACK TO TEXT
- 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
- 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.BACK TO TEXT
- 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.”BACK TO TEXT
- 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
- The low-hanging fruit. Searching for solutions only where the light is good. For instance, in one of my most direct experiences with real-world CBT, the therapist labelled her work as “CBT” but was fixated entirely on talking about my personal history, very “tell me about your mother,” stereotypical psychoanalysis. When gently challenged, it became clear that she had only hand-wavey explanations for how this constituted CBT, and there was no end in sight: she was going to indefinitely take my money while listening to me talk about my past, very expertly no doubt. “CBT” for $180/hour, ladies and gentlemen. BACK TO TEXT
- 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
- 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
- Cadegiani FA, Kater CE. Adrenal fatigue does not exist: a systematic review. BMC Endocr Disord. 2016 Aug;16(1):48. PubMed #27557747. ❐ PainSci #52878. ❐
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.
- 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
- 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
- McBeth J, Silman AJ, Gupta A, et al. Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: findings of a population-based prospective cohort study. Arthritis Rheum. 2007 Jan;56(1):360–71. PubMed #17195240. ❐ PainSci #54166. ❐
This unusual study showed that dysfunction of the hypothalamic–pituitary–adrenal (HPA) axis helps to distinguish those who will and will not develop new-onset chronic widespread pain. Many studies have shown that people with chronic widespread pain (CWP) show biological evidence of stress (hypercortisolic states), but such studies have generally been
unable to determine whether the observed HPA axis alterations preceded or were a consequence of having CWP. Neither did they account for the effects of anxiety, depression, life stresses, and sleep disturbance, all of which are associated with HPA axis dysfunction and may explain the observed relationship. The only way to establish the nature of the relationship is to conduct a prospective cohort study in which subjects who are free of CWP but are at risk of developing CWP are identified, their HPA axis function assessed, and their courses are followed over time in order to establish who develops pain. We conducted the first such study to test the hypothesis that among a group of subjects free of CWP, altered HPA function would mediate the relationship between psychosocial risk factors indicative of the process of somatization and the onset of symptoms of CWP. We further hypothesized that this relationship would be independent of the effect of concomitant psychosocial factors that may be confounding the relationship, including depressive symptoms and sleep disturbances.
This study is far from the last word on this topic, but it is intriguing evidence on one side of the debate.BACK TO TEXT
- Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed ed. New York: Times Books; 2004. Chapter 8: Immunity, Stress, and Disease; p. 144–185. Sapolsky goes deep on this topic, with this bottom line: “The system apparently did not evolve for dealing with numerous repetitions of coordinating the various on-and-off switches, and ultimately something uncoordinated occurs, increasing the risk that the system becomes autoimmune [inflammatory].” I elaborate more in a separate article, see Chronic, Subtle, Systemic Inflammation. BACK TO TEXT
It would be utterly negligent to exaggerate the implications of [how many health problems stress causes]. … Everything bad in human health now is not caused by stress, nor is it in our power to cure ourselves of all our worst medical nightmares merely by reducing stress and thinking healthy thoughts full of courage and spirit and love. Would that it were so. And shame on those who would profit from selling this view.
~ Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, p181
Sapolsky doesn’t pull any punches either, harshly reviewing one of the most egrious examples: Bernie Siegel’s ridiculous claims that cancer is “ultimately related to a lack of love.” It’s a brilliant takedown.BACK TO TEXT
- 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
- 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
- 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
- Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016 Sep;50(17):1030–41. PubMed #27535989. ❐ This comprehensive and authoritative review of the relationship between injury and “loading” (stress) in elite athletes makes it very clear that “load” can also refer to “internal” loads, emotional stressors, which are of course legion: anything from daily hassles to major emotional crises, as well as emotional stresses related to sport itself. BACK TO TEXT
- Ivarsson A, Johnson U, Andersen MB, et al. Psychosocial Factors and Sport Injuries: Meta-analyses for Prediction and Prevention. Sports Med. 2017 Feb;47(2):353–365. PubMed #27406221. ❐ BACK TO TEXT
- Li H, Moreland JJ, Peek-Asa C, Yang J. Preseason Anxiety and Depressive Symptoms and Prospective Injury Risk in Collegiate Athletes. Am J Sports Med. 2017 Jul;45(9):2148–2155. PubMed #28441037. ❐ BACK TO TEXT
- Saw AE, Main LC, Gastin PB. Monitoring the athlete training response: subjective self-reported measures trump commonly used objective measures: a systematic review. Br J Sports Med. 2016 Mar;50(5):281–91. PubMed #26423706. ❐ PainSci #52269. ❐ BACK TO TEXT
- De Ruddere L, Goubert L, Stevens MA, et al. Health care professionals' reactions to patient pain: impact of knowledge about medical evidence and psychosocial influences. J Pain. 2014 Mar;15(3):262–70. PubMed #24275317. ❐ BACK TO TEXT
- Synnott A, O'Keeffe M, Bunzli S, et al. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. J Physiother. 2015 Apr;61(2):68–76. PubMed #25812929. ❐ BACK TO TEXT
- 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.BACK TO TEXT
- 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.”BACK TO TEXT
- Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed ed. New York: Times Books; 2004. p. 164. “…the fewer social relationships a person has, the shorter his or her life expectancy, and the worse the impact of various infectious diseases. Relationships that are medically protective can take the form of marriage, contact with friends and extended family, church membership, or other group affiliations. This is a fairly consistent pattern that cuts across a lot of different settings. Moreover, these general findings are based on some careful prospective studies and are seen in both sexes and in different races, in American and European populations living in both urban and rural areas. Most important, this effect is big. The impact of social relationships on life expectancy appears to be at least as large as that of variables such as cigarette smoking, hypertension, obesity, and level of physical activity.” BACK TO TEXT
- Smith TO, Dainty JR, Williamson E, Martin KR. Association between musculoskeletal pain with social isolation and loneliness: analysis of the English Longitudinal Study of Ageing. Br J Pain. 2019 May;13(2):82–90. PubMed #31019689. ❐ PainSci #52275. ❐
This study looked for a link between chronic musculoskeletal pain, and loneliness and social isolation in several thousand older adults. They found that subject in pain were actually less likely to be socially isolated, but more likely to be lonely, an interesting apparent contradiction. However, loneliness is probably what matters: that is, social isolation isn’t a problem if you don’t feel socially isolated (lonely).BACK TO TEXT
- Quentin F. Gronau, Sara Van Erp, Daniel W. Heck, et al. A Bayesian model-averaged meta-analysis of the power pose effect with informed and default priors: the case of felt power. Comprehensive Results in Social Psychology. 2017;2(1):123–138. PainSci #53062. ❐
Carney et al infamously reported that “power poses” not only made people feel more powerful and daring, but that they had a biological fingerprint: more testosterone and less cortisol (stress hormone). And then the trouble started: “these power pose effects have recently come under considerable scrutiny,” which is a bit of an understatement: there have always been strong concerns about both the science itself and the way it was presented (premature hype).
This meta-analysis took a crack at producing the “last word” on this topic. It was part of a special edition of Comprehensive Results in Social Psychology, in which Carney herself was deeply involved (see CRSP special issue on power poses: what was the point and what did we learn?). It concluded that follow-up evidence for the original finding was “very strong,” and yet with a spectacular hold-your-horses caveat: “when the analysis is restricted to participants unfamiliar with the effect, the meta-analysis yields evidence that is only moderate.”
Translation: belief in the power of power posing will make you feel more powerful than power posing itself! Expectations seem to be the more potent active ingredient.
“Expansive postures” probably do make people feel more powerful … but only a little. Unless you believe in them, in which case you’re really off to the races. Which is fine. (“Why not both?”)BACK TO TEXT
- 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
- I discuss the myths of massage in great detail in Does Massage Therapy Work? BACK TO TEXT
- Massage supposedly “increases circulation,” but the evidence shows that it probably doesn’t, especially when compared to even light exercise. Also, relaxation shunts blood away from muscles into the core. For more information, see Does Massage Increase Circulation? Probably not, and definitely not as much as a little exercise. BACK TO TEXT
- A unreplicated and deeply flawed 2012 scientific study (Crane et al.) claimed to find that massage reduced inflammation in intensely exercised muscles. The profession of massage therapy took the conclusions at face value and claims that massage “reduces inflammation” are now common. For more information, see Massage Does Not Reduce Inflammation: The making of a new massage myth from a high-tech study of muscle samples after intense exercise. BACK TO TEXT
- 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
- 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.”BACK TO TEXT
- Not a real thing: a whimsical, imaginary diagnosis. But not entirely silly either. Maybe there should be such a diagnosis. BACK TO TEXT
- 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
- 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 class2 of sugars that may cause bowel irritation. If you experiment with it, do be alert for symptoms of irritable bowel syndrome.
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- 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
- 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
- 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
- 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
- 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
- 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. 7977 words. BACK TO TEXT
- 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
- 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.BACK TO TEXT
- 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.”BACK TO TEXT
- 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
- 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