Saba Javed, M.D. (Host): Hi, I'm Dr. Saba Javed, an assistant professor in Pain Medicine at MD Anderson Cancer Center. And we have Dr. Grace Kao, an associate professor in Pain Medicine, and this is the Cancerwise podcast. Hi, Grace. Thank you for being here today. So, we are here today to talk about how to manage mental health when you're dealing with chronic pain. As you already know, chronic pain affects all aspects of a patient's life, including work, activities and daily living, recreational activities. In an ideal multidisciplinary setting, the presence of a pain psychologist is crucial. And we're so fortunate to have you in our in our practice. So, to start this discussion, what is a pain psychologist and why would people see one? 

Grace Kao, Ph.D. Yeah, I think it's a really good question because many people may not automatically link psychology or the benefits of psychology with pain management. And I think the way that we've thought about pain throughout history, one maybe really common understanding of pain, is that we fix one, or the structural area of damage and pain is gone. But I think, you know, in the area that we work in chronic pain, in getting to know our patients and getting to know the research, we've really come to appreciate that pain affects and is affected by all different aspects of life. And so, when we see all these factors that impact pain, yes, biological, but also psychological, also social. And I think in that framework, pain psychology, pain psychologists make a lot of sense. In that pain psychologists, I think, can step in and be able to help people uncover and also start addressing those factors that impact pain. 

Saba Javed, M.D. (Host): I couldn't agree with you more, and just like you said, we see it a lot more in chronic pain patients and those experiencing pain for many, many years. So, what are some examples of different factors that might affect someone's pain experience? 

Grace Kao, Ph.D. Yeah. So, I think some of these factors may look like the ways that we respond to stress as an individual person and the ways that we've experienced pain in the past, our pain memories, the way we think about and feel about pain and even the rhythms of our daily lives. So, our sleep, our nutrition, our movement, general mood, anxiety, all these sources of information from the brain can actually impact pain signaling. 

Saba Javed, M.D. (Host): Yes, and pain can certainly present differently for different people and sometimes for chronic pain patients may have expressed, have expressed concerns about pain being dismissed if we refer them to pain psychology. Any advice for these concerns? 

Grace Kao, Ph.D. Yeah, definitely. So, I think as we're having this conversation around the psychology of pain, it's also really important to keep in mind that connecting with a pain psychologist or thinking about pain management from a psychological perspective absolutely does not mean that pain is not real or it's all in one's head. And in fact, I think what it doesmean is that we really want to address pain comprehensively, and that pain responds best when it's treated in more than one way and with the collaboration of multiple specialties and specialists. 

Saba Javed, M.D. (Host): Absolutely. And Dr. Kao, so why do you think pain is so complicated, and why do we experience it? 

Grace Kao, Ph.D. Yeah, pain, pain is really complicated. I think, as you and I have both appreciated and hearing about pain from our patients, trying to understand pain, and then just in the many, many discussions that we've had working together in chronic pain. One way that I think we can think about pain is as this really intricate alarm system in our bodies. And sometimes that system works really well. Sometimes it can be a little oversensitive, sometimes it can even malfunction and need a little bit of a reset. So, essentially, pain tells us a lot about threat and about things that might harm us, like a hot stove, a sharp nail or bad food. I think this threat or warning then gets interpreted through our memories, our emotions, our experiences. And that whole process can be very complex. 

Saba Javed, M.D. (Host): And just to that point, I know we spoke earlier about chronic pain being complicated in different settings. Acute versus chronic, we typically define acute pain as pain that's new in chronic pain. That's pain; pain that's been going on for over three months or 90 days. In your perspective or from a pain psychologist, how do you define chronic pain and how does that impact, ultimately, the pain for patients? 

Grace Kao, Ph.D. Yeah, no, really good point. I think as we're thinking about chronic pain or really thinking about it as pain that's lasting beyond what we typically think about as a timeframe that any structural or tissue damage would have healed. So, in these cases, that pain signal is no longer giving us useful information, at least about structural damage. Still, sometimes our minds and our bodies continue to produce that threat alarm. So, like we talked about, with it being a bit oversensitive or even faulty at times. When that happens, it can contribute to very real pain. Now, of course, I think in some of the cases that we see and with the patients that we work with, there can be other processes that are ongoing which can make pain even more complex. So, with something like cancer, we're thinking about ongoing disease treatment, procedure-related contributors to pain. And these are all existing alongside some of the psychosocial factors that we talked about as well. 

Saba Javed, M.D. (Host): Absolutely. And you mentioned these psychosocial factors as being important. We know studies have shown that patients who have anxiety and depression typically have higher levels of pain in general. Can you help us explain how mental health affects pain? 

Grace Kao, Ph.D. Yeah. So, our minds and bodies are so, so intimately connected. Like, if we think about butterflies in our stomach, or if someone says they have a stress headache, both of those are really great examples of our bodies really displaying what may be happening with our thoughts and our emotions. And I think, as you alluded to a little bit earlier, just from neuroscience research, we know that low mood, worry, anxiety, all of these things are processed in really similar spaces in the brain as pain. So it makes a lot of sense that they all might impact each other. And I think just from our own experiences, too, of having had pain. So, say if we imagine having body aches with the flu, with it being flu season right now, and thinking about being in that state and just being more easily irritated and frustrated and angry and sad because we can't do the things that we normally would be able to do. And then you multiply that by one month, two month, three months of being in this state where, for some of our patients, they don't know when that's going to get better. And so I think as we imagine that prolonged sense of stress, it helps us to connect a bit better with our patients, with friends, family who are navigating chronic pain. 

Saba Javed, M.D. (Host): Absolutely. And I know many of our patients come to us experiencing significant stress and distress due to this emotional toll that's taken on their lives, as you mentioned. And I believe that a key part of our responsibility as pain physicians, pain providers is to help alleviate some of this distress. 

Grace Kao, Ph.D. Yeah, no, absolutely. I had a mentor actually, when I was going through pain psychology fellowship who would say, "We really need to equip our chronic pain patients with this Olympic level-coping skill set to help navigate these very formidable and understandable challenges that come along with navigating chronic pain." And I think that's always stuck with me all of these years as one point of respect and admiration for some of the patients that we see. For many of the patients that we see who some, with the help of pain psychology, have developed this Olympic level-expertise in navigating how to function, how to live life despite pain. 

Saba Javed, M.D. (Host): Great advice by your mentor, Dr. Kao. I can see now where your empathy in helping your patients really comes from. It's fantastic. So, how does pain psychology help with treating pain? 

Grace Kao, Ph.D. Yeah. So, I think given all the things that we've just talked about, the supporting and empowering of patients with pain coping resources and then helping to identify ways to decrease stress, to be able to address those factors that might make pain worse is a really important role that pain psychologists can play on the pain management team. And I think that can look a couple of different ways. So, maybe teaching and practicing some of these non-interventional, non-pharmacological strategies with our patients turn down that pain and stress response. It may look like supporting and problem solving with patients to improve quality of life while navigating pain. It may look like providing a safe space to process and address some of those emotional health factors that we just talked about: stress, worry, anxiety that also affect us when we have chronic pain. 

Saba Javed, M.D. (Host): Absolutely. And I know we share multiple patients together, patients that were referred to you to help assisting with their chronic pain management. What techniques can patients use to help cope with chronic pain?

Grace Kao, Ph.D. Yeah. I think several areas that pain psychologists might look at to work with patients on and helping navigate chronic pain. One area may be biobehavioral techniques or strategies that really turn on the body's own relaxation response. And these may be breathing based, muscle relaxation based, mindfulness, visualization based, all used to help downregulate that pain and stress response. We may also look at cognitive techniques. So, ways that we're thinking about pain that might get automatically associated with that pain signal. And these strategies really tap into how sensation can be connected with our thoughts and our emotions and our behaviors to also impact pain. 

Saba Javed, M.D. (Host): Can you give us an example of this cognitive strategy and how a patient can try to change their thinking about pain? 

Grace Kao, Ph.D. Yeah. So, one strategy we may think about for patients whose thinking becomes a lot more absolute or a lot more black and white, where they're thinking about pain and pain limitations may be something we call "thinking in the gray." And so, we walk through a couple of steps with patients. First, we work on identifying and tracking those thought patterns that might become a lot more narrow. So, for example, if we hear patients talking about or expressing, "Hey, I can't do anything when I have pain" or "when I have pain, I might as well just stay in bed all day" or "pain will absolutely ruin my life." In those instances, we take a look at those thoughts in those thought patterns and consider in our black and white framework, "Hey, these thoughts may be all black" or recognizing that they don't leave a lot of room for other possibilities. And in that recognition, we may also be understanding maybe how the absolute nature of some of those thoughts can actually be promoting more fear or stress or anxiety that can add to what's already going on with pain. So thirdly, and maybe the more important step here, is that we want to play with those thoughts a little bit and introduce more flexibility. So shifting those thoughts into a more gray area. And then these examples, for, that we just talked about, it may be something like, "well, I'm not very comfortable right now. I can see how it goes. I can plan some more breaks in my day. If I need the support, I'll ask for it then." So, really being able to change the automatic message sometimes that we have about pain and the message that we give our brains about pain help lower that sense of threat and arousal and help again downregulate that pain response. 

Saba Javed, M.D. (Host): Very well said and thanks for that strategy, Dr. Kao. Anything else we want others to know about pain psychology? 

Grace Kao, Ph.D. Yeah. So, as we're talking through all of this, I think maybe one way to sum up some of these themes that we've been speaking about is really to shift our perspective from thinking about pain as a singular symptom to understanding pain as an experience, that pain impacts the day to day, people's functioning, people's moods, people's relationships. And in that understanding of pain as an experience, I think there's then an opportunity to look at ways that we treat our bodies, but also look at ways that we are treating and supporting our minds for the sake of better pain management and better health overall. 

Saba Javed, M.D. (Host): Thanks, Dr. Kao, for being here today and for having this intriguing discussion. I hope this is going to be very beneficial for patients. For more information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MD Anderson.org. And thanks for listening to the Cancerwise podcast from MD Anderson Cancer Center.