Damage isn’t always the cause of pain, and it’s never the only culprit. Pain, it turns out, is much more interesting than that.
Here’s what we do know: Science reveals that pain is biopsychosocial, produced by a combination of biological, psychological (emotional, cognitive, behavioral), and sociological (social, environmental, contextual) factors that work together to create the pain we feel. Pain lives in the glorious, messy middle of all the things that make you, you.
While holistic healthcare and mind-body medicine have tried to change the narrative for decades, even they miss the big picture when it comes to pain. Because understanding pain isn’t just about connecting mind and body. The things going on around us — not just inside of us — change pain, too.
In order to treat pain, therefore, we can’t just fixate on the part that hurts; we must instead treat all of you.
Pain is biological
The first pillar, the biological domain of pain, includes the ingredients we’ve heard the most about: genetics, tissue damage, system dysfunction, inflammation, the wear and tear of an aging body, neurotransmitters, hormones, diet, sleep, exercise. Anything and everything that can go wrong with the human body lives here: blights and diseases, afflictions and infections, things that break, tear, swell, and pull.
For Sam, [a teen patient of mine] with crippling pain that kept him in bed for four years, this included a family history of migraine, poor sleep, inadequate nutrition, changes in hormones and brain chemicals, eye strain, and inflammation.
Biological factors are critically important when it comes to pain and cannot be ignored. They are commonly treated with medical interventions like medications and surgeries — which, while extremely helpful for acute pain, often saving limbs and lives — are considerably less helpful for chronic pain.
Of note, just because pain has a biological component doesn’t mean it’s genetic destiny or assigned at birth — that is, just because Dad suffered from sciatica doesn’t necessarily mean we will. In fact, there’s no single “pain gene” passed down from generation to generation. Rather, scientists believe that hundreds of genes contribute to the pain experience. Some of these genes help determine our “pain threshold,” or how much input we can tolerate until it hurts.
But even if the genetic deck is stacked against us, humans are never the product of genes alone. We are always a combination of our genes (nature) and our environment (nurture). So while some painful conditions are heritable to some degree, 100% of them, from arthritis to sickle cell disease, are massively influenced by social and environmental factors: things like diet, culture, socioeconomic status, trauma, and stress. Which brings us to the next, and most misunderstood, pillar of pain: the psychological domain.
Pain is psychological
The psychological domain of pain is less commonly addressed due to pervasive, and understandable, stigma. This is fed by an ongoing cultural disconnect between emotional and physical pain. Western medicine tells us, for example, that either our pain is physical — in which case, we need to see a physician — or our pain is emotional, in which case we’re sent to a psychotherapist. But neuroscience reveals that pain is never either/or; it is always both.
Psychological influences, frequently rejected and ignored, include [factors] like perceptions, expectations, and the meaning assigned to sensations. This domain also includes some components [such as] thoughts, attention and distraction, and emotions. Emotional contributors to Sam’s chronic pain, for example, included the depression and sadness that made his body hurt more, and the untreated stress and anxiety that kept his nervous system in overdrive.
Rather than an objective indicator of physical damage, we now know that pain is a predictive process constructed in relation to what’s going on inside of us and around us in any given moment.
Coping behaviors, or how we deal with pain once it starts, also live in the psychological domain of pain. These include the behaviors we decide to (or not to!) engage in when we wake up every morning — like whether we go for that walk, and how much alcohol and other substances we consume. Sam coped with pain by avoiding movement and activity, swapping soccer for videogames. This sedentariness, while normal and natural when we’re in pain, made his body weaker, his joints stiffer, his muscles tighter, and his pain system more sensitive. A gradual return to movement and beloved hobbies was a significant part of Sam’s healing protocol.
You’ll notice that “psych” factors overlap with “bio” factors, and this is critical. Because these divisions are merely lines drawn in the sand. When it comes to pain, everything is connected.
Pain is sociological
The third pillar of pain is the social, or sociological, domain of pain. I call this the “everything else” domain because of its immense breadth. This pillar includes all of the social, economic, and cultural factors that impact our health and well-being. This covers sex, gender, race, and ethnicity; socioeconomic status and access to care; social factors like isolation and social support; trauma and abuse, which play a more profound role in pain than we ever imagined; environmental stressors like poverty and racism; and larger contexts, including societal norms and expectations.
Social factors influencing Sam’s health included social isolation, missing school, and falling behind socially and academically as a result. After being stuck at home for four long years, it’s no coincidence that his first treatment goal was to reconnect with friends and rejoin his soccer team.
Together, all of these factors combine to create the pain we feel. No one ingredient is the sole contributor; all factors matter, all of the time. Pain is never — not ever — due to just one thing. This is extremely hopeful knowledge, because it means there are many things that can adjust pain volume beyond pills — and that we have much more control than we ever realized.
Expanding our definition to include all the factors that comprise pain finally yields a clearer picture: Pain is our brain’s opinion of how much danger we’re in, based on all available data. Rather than an objective indicator of physical damage, we now know that pain is a predictive process constructed in relation to what’s going on inside of us and around us in any given moment. This enables me to offer you an updated definition of pain: Pain is a biopsychosocial, subjective experience constructed by the brain, with inputs from our body and our environment, to make meaning of messages, predict what’s to come, and determine how to best respond to ensure our survival.
This article The 3 pillars of pain: A radical new way to understand why you hurt is featured on Big Think.