What Do Chronic Pain, Anxiety, and Depression Have in Common?

When we think about chronic pain, anxiety, and depression, we often think of them as completely separate conditions with different treatment targets. But, what if there are some important similarities in the way the brain and nervous system can contribute to all three?

This is one of the ideas explored in the work of physician and researcher Dr. Howard Schubiner, MD, particularly his book called "Unlearn your Pain" about neuroplastic pain and the mind-body connection. His approach builds on the understanding that our physical and emotional experiences are deeply interconnected, and that the brain plays an important role in how we experience pain, stress, and other symptoms.

Here are four important connections between the three: chronic pain, depression and anxiety.

"Your body is not a problem to be fixed."

They can involve biological, psychological, and social factors

We often think about mental health conditions as being influenced by a combination of

biology, psychology, and our environment. Anxiety and depression, for example, can have biological, psychological, relational, and social contributors.

What you may not know is that chronic pain can be understood through the same biopsychosocial lens. This doesn't mean that chronic pain is imaginary or “all in your head.” Pain is real, and there are many medical conditions in which an identifiable physical process is an important contributor to pain.

At the same time, pain does not always have a physical root cause that can be explained by an injury or tissue damage. The brain and nervous system play an essential role in creating the experience of pain, and factors such as stress, painful emotions, trauma, and your social environment can influence how pain is processed and felt.

Schubiner's work also describes a phenomenon called neuroplastic pain: pain that can persist because the nervous system has learned and reinforced pain pathways, even when there is no ongoing tissue damage that adequately explains the severity or persistence of the symptoms. According to his research, about 88% of chronic back and neck pain is actually likely to be neuroplastic (Schubiner et al., 2024). His model emphasizes that these symptoms are still very real experiences of pain, and not at all "made up" or "faked."

This is one reason the biopsychosocial model can be so helpful: it means there are many routes towards healing!

Symptoms are often the nervous system trying to protect you

Your nervous system has one very important job: to protect you.

Pain itself is a protective mechanism. When you injure yourself, pain draws your attention to the area and encourages you to protect it while it heals, so you don't re-injure yourself.

Anxiety serves a protective function too. When your brain perceives danger, your nervous system can mobilize you to respond through increased alertness, muscle tension, a racing heart, or the urge to fight-or-flight.

Even though these responses can become extremely uncomfortable and unwanted, they developed for a reason.

The same protective system can become overly sensitive.

If your brain has learned to associate certain sensations, situations, emotions, or experiences with danger, it may begin responding to those cues even when there isn't an immediate threat.

Schubiner describes this as a process in which neural pathways can become reinforced over time. In chronic pain, for example, fear, stress, and attention to symptoms can contribute to a cycle that amplifies the pain experience (see my post about the fear-pain cycle).

This doesn't mean you or your nervous system is “broken," it just means it's been trying too hard to protect you in ways that no longer serve you anymore.

Trauma and chronic stress can affect the way our nervous system responds to threat

Another important connection is the relationship between trauma, chronic stress, and the nervous system.

People who have experienced trauma or childhood adversity may develop heightened sensitivity to threat. This can include increased vigilance, changes in stress hormones (i.e. cortisol), and a tendency for the brain to more readily detect potential danger.

And trauma doesn't have to look one particular way.

It can include "Big T" Trauma experiences such as abuse or violence, but "Small t" traumas such as chronic invalidation, emotional neglect, unpredictability or instability can also affect how a person learns to experience safety and threat. Research increasingly supports an association between trauma exposure and chronic pain, although the relationship is complex and nuanced.

Your symptoms are real. And your nervous system is part of the picture.

One of the most important things I take from this work is that a mind-body approach should never be used to dismiss someone's physical experience.

If you have chronic pain or other persistent physical symptoms, appropriate medical evaluation is important. Neuroplastic or centralized pain is not the explanation for every pain condition, and psychological factors should not be used to explain away symptoms that require medical attention.

But we also don't have to treat the mind and body as completely separate.

Your nervous system is part of your body.

Your emotions affect your biology.

Your life experiences shape your brain.

And your brain influences how you experience your body.

For some people living with chronic pain, anxiety, depression, or trauma-related symptoms, healing may involve more than simply treating the symptom itself. It may also involve learning to recognize patterns of threat, developing a greater sense of safety in the body, processing difficult emotional experiences, and developing a different relationship with physical sensations.

This is where therapy can help! Talking to a trusted person, in a safe, nonjudgmental space is crucial for healing your relationship with your body. In our work together, I want you to feel heard, validated and understood. You are not alone and there is hope for healing!

Book an intro call with me today to see how I can support your chronic pain!

References

Schubiner, H. H., Lowry, W. J., Heule, M., Ashar, Y. K., Lim, M., Mekaru, S., Kitts, T., & Lumley, M. A. (2024). Application of a clinical approach to diagnosing primary pain: Prevalence and correlates of primary back and neck pain in a community physiatry clinic. The Journal of Pain, 25(3), 672–681. https://doi.org/10.1016/j.jpain.2023.09.019

Schubiner, H., & Betzold, M. (2016). Unlearn your pain: A 28-day process to reprogram your brain (3rd ed.). Mind Body Publishing.