Why Me?

This is a question most pain patients ask themselves at some point. Rarely does this question result in a satisfactory answer – the truth is, the only good answer would be if it were not you.

While asking “why me?” is often a bad idea, knowing the answer to “why” as it relates to your pain can have some benefit. There may be positive outcomes that grow from knowledge of the cause, source, or origin of your pain. Knowledge of why can guide treatment, including psychological approaches taken, and can guide the course of your rehabilitation and overall well-being. Let’s explore three common answers to “Why?” – injury, illness, or unknown.

If your pain is the result of a physical injury (such as a slip and fall or car accident) then there may be some associated psychological trauma. Some people may suffer from anxiety and worry, even posttraumatic stress (PTSD). You may begin to fear that such an event could occur again in the future. Certain behaviors or events may be avoided, even to the point of phobia. What is called “guarding” can occur, leading to pain sufferers holding their limbs in odd positions, even padding them to avoid re-injury, or avoiding physical contact with people. Obviously it makes sense to try to avoid worsening your situation or “making the same mistake twice,” so to speak. However, if such psychological tension or behavioral change is unconscious (and even if not), these reactions to your pain onset can be unnecessarily troubling. (For instance, if a traumatic event caused the pain, then every time you feel a twinge of pain you are reminded of that traumatic event – this pattern only makes the physical and emotional pain that much harder to endure.) Studies have shown that a history of trauma (even long before your injury or pain onset) predisposes people to experiencing worse pain, as the physical and psychological issues intertwine, and your psyche is made somewhat more vulnerable to negative feelings. Additionally, research has proven that posttraumatic stress (as a result of a physical trauma) exacerbates pain and disability by way of increased depression – meaning, trauma leads to PTSD which leads to depression, which impacts pain and functional status (Roth, Geisser, & Bates, 2008). By treating the PTSD, we can treat the depression, and thus reduce or better manage the pain. This becomes a true example of what is called (in mental health) a pain disorder, where pain leads to psychological issues, and psychological issues lead to pain – there is an interplay between both sides of the coin. The good news is, if we intervene on one side, it can positively affect the other.

Another aspect of trauma or accident as the onset of pain is that there can be an outlet for blame – anger and frustration can be directed at the other driver, the building owner and so on. This is good and bad – nice to have a target, bad because then we can get “stuck” on trying to find remediation, financial or otherwise. Such belief structures also guide treatment in the way I might encourage or discourage such outward, externalization of your anger or distress – for some people this behavior may help, for others it is quite harmful, but either way it is an important piece of information.

If illness (whether chronic or brief) is the cause of your pain, the implications for your outlook may be a bit different than if there were an injury. For example, pain related to diabetes may lead patients to experience guilt for not catching or controlling symptoms. Questions like “could I have done something different” and second guessing can occur. Periods of overcorrection may result – “I ate that dessert and my neuropathy got worse, from now on, only broccoli for me!”. And the reverse can occur – beliefs may arise wherein any increase in pain levels can lead to fears of worsening health or illness (“pain was the first sign of my cancer, does this pain mean the cancer’s back!?”). These flare-ups of pain, and thus anxiety, can be PTSD-like in that the traumatic experience of a cancer scare or a heart attack or a diabetic event may be re-lived every time the pain gets worse. And, there are psychological implications for the behavioral reaction you choose – some people find extremes of either reporting to doctors even the most minute changes in pain, for fear of illness recurrence; others fear that telling of the pain will bring on such bad news, so they avoid telling the doctor to avoid any potentially unpleasant truths. Obviously, both extremes can be detrimental to your physical and mental health, and moderation is key. (And this issue is complicated, as reporting increased pain to your treating physician can be important to track disease progress, even if pain does not always tie back to the illness.)

So with pain tied to an illness, the risk may seem ever present, always waiting for a symptom flare-up to lead to worse pain (or for the pain to signal a symptom of illness). With an illness-related pain, the course may be more gradual and hidden, not knowing when or where symptom changes will lead to anxiety, whereas in accident-related pain, you may be able to more easily and actively avoid certain situations – it is more overt and externalized. There is also more a component of self-blame that may occur (versus outward or other blame with an accident). And the biggest difference with illness-related onset may be my reaction as a psychologist – knowing that your negative mood is not just a result of a bad pain day, but tied to fears of illness – this changes my approach to your therapy.

Finally, not knowing the origin of your pain can present a host of other issues. Where the other two causes can result in all the emotions and behaviors noted, at least those cases allow people to direct their concern at a specific cause. With no known source of the pain, anxiety can spiral to an even greater degree. Fear and paranoia even. And consider this – if you know that a car accident or a poor diet led to your pain, you can at least try to avoid these triggers. However, with no clear cause there may be no clear coping mechanism – that can be very scary and debilitating. Your worldview may go from “bad things happen only to bad people” to “the world is dangerous and unfair.” Without a known cause, many patients begin to lose their faith in medicine and doctors – “why can’t you figure out what’s wrong, it’s your job!?” And the reaction from the medical profession often is negative in itself – some professionals will question patients’ pain and wonder if it is real at all, coming from the perspective that if it cannot be diagnosed then one of the solutions is to label it as fiction. The psychological implications for you as the patient are obvious in this scenario.

Regardless of the reason for your pain (the why), what we are really talking about here is a consideration of how – how your pain began, how your worldview is impacted by your beliefs about your pain, and how this belief structure can impact you thoughts, emotions, behaviors, every aspect of your life. What this means is that there can be a trickle down effect, even a cyclical effect (in that greater emotional distress and poor coping can actually worsen pain). To give a simple visual, consider this:

PAIN CAUSE -> PAIN BELIEFS -> EMOTIONS -> BEHAVIORS -> FUNCTIONING

…for instance…

CAR CRASH -> CARS HURT -> FEAR -> AVOID CARS ->ISOLATE/DON’T GO OUT

…which of course means you stay home alone and focus on your pain, which makes the pain feel worse, and around and around you go…

Or, consider this quote a patient shared with me: Watch your thoughts, for they become your words. Choose your words, for they become actions. Understand your actions, for they become habits. Study your habits, for they will become your character. Develop your character, for it becomes your destiny.

The point of this post is not to increase your distress, or to oversimplify your experience. What is meant is to direct you regarding the questions you might want to ask, or issues you might want to raise. It is vital that you discuss your feelings and beliefs about the pain onset with a medical or psychological professional. Knowing this answer to “why” (or how) can impact where we professionals intervene, and how we do so (as treating anxiety is different from treating depression, or we may need to address your anger at others versus anger at yourself). Working through your beliefs can then have a positive cascading effect on the pattern drawn above. Studies have shown that such therapeutic exploration can reduce posttraumatic stress, anxiety, negative behaviors, and so on.

You don’t want to build further assumptions atop the old ones – our feelings are often correct, but can be misguided if not challenged from time to time. If you start with the belief that all pain is a sign of terrible illness, or that car accidents can occur at any minute, you have taken your negative experience and magnified it, stretched it, and made it something bigger (and less true) than how it began. On that unsteady and faulty base, whatever you build atop it is sure to lead to distress. One of the best interventions we can provide is to help you separate out faulty or illogical beliefs from the facts – your emotions may tell you that the world is filled with danger, and while the emotion is valid, the belief is skewed – psychology can help you think more clearly. Techniques like cognitive therapy and rational emotive therapy can help you to see what beliefs are important (e.g., always report increased pain to your physician, always wear a seatbelt) and distinguish which beliefs you can alter or relinquish (e.g., not every car ride will end in an accident, it is unlikely that one meal off of your diabetic diet caused your pain).

So while you may not like the answer to “why me?,” you should do your best to learn of the origin of your pain and share that information with providers – knowing the “why” can help you (and me) answer the “how” to improve your quality of life. We can’t take away your pain or change the past, but we can reduce your distress going forward by helping you re-evaluate your belief and start from a solid base.

Reference
Roth, R. S., Geisser, M. E., & Bates, R. (2008). The relation of post-traumatic stress symptoms to depression and pain in patients with accident-related chronic pain. The Journal of Pain, 9, 588-596.

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