Emotions, Alexithymia and Chronic Pain

The underlying concept behind the SIRPA approach is that pain and many other persistent health conditions are often triggered, or perpetuate, as a result of the build-up of unresolved emotions related to past or current chronic stress or trauma. These symptoms are part of the brain’s primal protective/‘fight or flight’ response.  These days though ‘threats’ are generally more of the psychological kind, rather than potentially life-threatening situations, like facing a lion or a sabre-toothed tiger. For example, a result of how we react to what is going on in our lives (e.g. over-analysing, ruminating, worrying etc), rather than just what is actually happening.

There is a significant amount of research linking chronic pain with chronic stress and past trauma, plus there is also a large body of evidence linking adverse childhood experiences with the onset of chronic pain and other major health problems in later life.  In addition, there are studies demonstrating the link between chronic stress and trauma with inflammatory responses in the body.  The inflammatory response is activated when the ‘fight or flight’ response is activated, which explains how pain and inflammation can be linked.

Some studies also investigated why acute pain after an injury becomes chronic. These demonstrate that it is not actually the severity of the tissue damage that is relevant in whether pain persists but whether the individual has had: depression at the time of the injury, experienced past trauma, loss of hope for the future, anxiety or had negative beliefs that the pain might become permanent.

Evidence related to our perception of pain also demonstrates that it is not the severity of the injury that determines how much pain we perceive, but: what is happening right now, our previous experiences, beliefs, fears and expectations.

The importance of emotional health

The one main factor linking all these is emotions and there is growing evidence demonstrating the link between repressed emotions and poor health.  One paper from 2018 concluded that; ‘… it is clear that expressing one’s true emotions and the feeling is crucial to physical health, mental health, and general wellbeing, while a reliance on concealment gives rise to a barrier to good health.’

My own work in this field has continued to evolve since I visited Dr John E Sarno in 2007 and I credit much of my learning not just from courses and colleagues, but from the hundreds of patients I have worked with since that time, as well as from my own personal experiences.

Over the years I have become more aware of the importance of clients being able to actually feel emotions, rather than just consciously focusing on the story related to them, when working with chronic pain.  The extensive work of trauma specialists, such as Peter Levine MD and Bessel van der Kolk MD on trauma and the impact trauma has on our bodies has played a part in this, as well as reinforcing the importance of learning how to allow emotions to flow unimpeded through the body.

Unfortunately, even without having had trauma or severe stress in our past, most of us in the Western world learned to repress our emotions because of our environment and experiences in childhood.  This might have been related to trauma but also might have been learned due to having to conform to parental/school/cultural/social/religious expectations while growing up.

Over the years I became more aware of how patients are often unaware of how they feel and how, even when they are aware of an emotion, they are not consciously aware of the impact this has on their body.  Although we might have learned to suppress emotions as a way to help us cope or fit in (or at least try to), in later life this becomes an unconscious,  protective response by our primal brain from what is perceived to be a ‘threat’ (uncomfortable emotions and feelings), often without consciously being aware this is happening.

As an example, on a more extreme level, if someone grew up with a volatile Father they may have learned that anger was dangerous and even more dangerous might have been for them to express it themselves when he was around.  Unsurprisingly suppressing anger helped them cope and in time they learned to repress it because the primal brain is trying to keep them safe when even mild anger is triggered inside them.  I have observed this with some clients who had no awareness of ever feeling angry at all and believed they were not an angry person because they never ‘felt’ it.  What they were unaware of was that feelings of frustration or irritation etc, is a form of anger and that the persistent pain they were experiencing was actually the body expressing their unresolved emotional pain.  For others, maybe they learned to bottle up other emotions that might have made them a target for bullying or not fitting in.

Alexithymia

What I realised was that this was not just a few people, but the majority of my patients have little awareness of sensations in their body related to emotions and of course this was why their emotional ‘pain’ was being expressed physically.  The clinical term for this is Alexithymia, which indicates that someone has difficulty with emotional awareness, identifying feelings, self-regulation and emotional expression.

I would suggest that this is a broad term and although it has been linked with Autism it has also been linked with depression and chronic pain.  Studies have also shown that Alexithymia puts people with it at greater risk of developing chronic pain.  In one paper Alexithymia was linked with: general chronic pain, Fibromyalgia, Chronic Regional Pain Disorder, Temporomandibular Disorders, Migraines and Irritable Bowel Syndrome.

Alexithymia is considered to be a personal trait and has also been linked with stress and past trauma.  I would suggest that it is very common at some level and certainly most of my patients who present with chronic pain and other persistent symptoms have difficulty feeling and expressing emotions.  Because of that, emotions are not able to flow through their body and be seen and felt, completing the energetic cycle of that emotion.

One paper in 2011 reviewed the previous 10 years of studies which had looked at the links between emotional processes and persistent pain and they concluded that; ‘Emotions are integral to the conceptualization, assessment, and treatment of persistent pain. Research should clarify when to eliminate or attenuate negative emotions, and when to access, experience, and express them.’

And in this article in The Guardian in 2024, they discuss the increasing evidence demonstrating the impact poor interoception has on our general health and wellbeing, including our mental health.

Developing Emotional Awareness

This is why one of the first things I do with clients is to take them through an emotional awareness exercise (see below) to observe how much awareness they have of internal bodily sensations, including those related to emotions.

The aim for teaching emotional awareness is to help individuals develop their ‘felt’ sense.  Like vision, hearing, taste, smell and touch this is also a sense, but an internal one, related to the ability to bring awareness to the ever-changing sensations inside their body.  This trains us to move our attention from actions, thoughts and what is going on outside our body to being present with our internal experience. These transient sensations are happening all the time and might include temperature changes, feelings (such as pain, twitches, heaviness, fullness, an itch, tension, tingling etc), colours, textures etc.

It’s often not emotions that feel threatening to us but the physical sensations related to these emotions as they begin to surface before being able to flow through the body.  Consider how you feel when an uncomfortable emotion surfaces, maybe anger, and how your heart beats faster and you notice an increase in tension and maybe a heaviness in your chest?  If you are someone who has learned that anger is dangerous, then you will unconsciously perceive this to be a threat, so your primal brain will immediately react to prevent you from feeling it.  The physical reaction might just be tension or it might become a tension headache or any other pain or physical symptom.

Typical unhealthy strategies people adopt, often unconsciously, to avoid having to ‘feel’ these surfacing emotions include self-soothing, such as: over-eating, alcohol, drugs, smoking.  Another way is to distract yourself from feeling by keeping busy, always being on the move.  People can also react to uncomfortable emotions by indulging in them, maybe through ruminating, over-analysing or worrying.

There is another way to deal with emotions when they are triggered though and that is to allow emotions to surface to be felt and allowed to flow through our body and be acknowledged with warmth and compassion.

This can be challenging for many people though, especially people who have experienced trauma.  In fact, even just being still can feel overwhelming because then there is no distraction and unresolved emotions can begin to surface.  Closing your eyes can also be too much for some people with past trauma, so practicing emotional awareness with a lowered gaze might be a better way to start practicing.

This is why it is important for people to gradually develop their felt sense over time and to start by learning how to ground themselves and self-soothe in order to be able to learn to build up their capacity to hold uncomfortable emotions as they develop their tolerance, without becoming overwhelmed.

One simple way to begin to develop your felt sense/interoception is to use a process I call – Pause:Breathe:Feel:Reassure. This is a quick, easy process which can be used anywhere and at any time, whether it’s when you notice a button has been pressed or a symptom has been triggered or increased or just to practice little and often to gradually build up your awareness.

Grounding Tool

The 321 grounding tool can be helpful to learn and then use if things become too uncomfortable emotionally while you are quietly allowing yourself to notice sensations in your body with curiosity.   If using an emotional awareness/somatic process it can be helpful to open your eyes and initially make a fist and release a few times, plus move your toes and feet around and then name:

• 3 things you can see
• 2 things you can feel/touch
• 1 things you can hear

Once you feel calmer you can then restart the process as you gradually build up your window of tolerance and capacity to allow your emotions to surface and flow.

Self-soothing

There are many ways to resource yourself, for example as a way to self-soothe and here are three simple examples.

1. Use HeartMath breathing – rest your attention on your heart and imagine the air circulating around your heart as you breathe in and again as you breathe out. As you breathe in allow your belly to rise away from your backboe and to settle back down as you breathe out.  Gradually slow you breathing down to a slow, rhythmical pace.  Counting 5 seconds slowly as you breathe in and 5 seconds as you breathe out helps you calm your breathing down, while also calming the stress response and boosting your relaxation response.  After doing this for a while, bring to mind something or someone you love and allow a feeling of love or compassion to build, helping to boost the relaxation response even more.

2. Speak compassionately and reassuringly to yourself as you stroke your hands together or stroke your face. Alternatively by crossing your arms you can stroke your arms from your shoulder to your elbows.  This has been shown to calm the emotional centres of the brain.

3. Place your hand over your heart and repeat to yourself – ‘I hear you. I feel you. I love you’

Pendulation

Pendulation is the technique Peter Levine MD uses to help gradually build the tolerance of feeling emotions, without feeling overwhelmed.  In other words, practising emotional awareness or somatic tracking and stopping to ground yourself and/or self-soothe each time feelings become too much, then going back into the practise.  This can help you build your window of tolerance and over time you will develop your felt sense and ability to allow emotions to be felt and expressed, rather than avoided, indulged in or repressed.

When allowed to do so emotions, when triggered, will surface like a wave coming up a beach.  They hang around for a little while and then flow back down.  According to author and brain scientist, Jill Bolte PhD, emotions take about 90 seconds to flow through and settle down again. Through developing our felt sense, we learn more about the landscape within us and our ability to allow our emotions to be acknowledged and expressed, therefore allowing them to complete their normal cycle.

Click here for a short video I recorded about grounding and pendulation.

Introducing an Emotional Awareness Exercise

In order to help you develop your felt sense, I have recorded an audio.  The first half explains the process of emotional awareness, while the second half allows you to start practising it.

Click HERE to listen and from 12.45 minutes you will be able to follow the strategy I explain.

Georgie Oldfield MCSP
Physiotherapist & Founder of SIRPA

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