Dr Thanh-Tam Pham - 08/01/2023

Howard Schubiner in his book “Unlearn Your Pain “ gave a very comprehensive analysis of the factors leading to chronic pain as summarised below:

The Pathways of Pain.

Pain begins when nerve pathways from the brain to the body are stimulated. Over time, these pathways can become wired into the brain circuitry. The nervous system learns to create chronic pain, even though there is no serious medical condition, and even though any injury that may have precipitated the pain has long ago healed.

“Phantom limb” pain is felt in an arm or a leg that has been amputated. The pain is caused by sensitized nerve connections and the creation of nerve pathways in the brain.

The best way to end chronic pain is by retraining the brain. Most people do not realize that the brain can both create and cure chronic pain conditions especially conditions that do not have a clear pathology in the body.

Stress and Pain. 

Pain cannot be felt without the brain, which interprets nerve signals and transform them into the experience of pain. It is important to feel pain so we can protect ourselves from danger. However, these pathways often tend to get reinforced over time with our reactions to the pain. People with chronic pain will react to that pain with fear, anger, anxiety, frustration, and other worrisome thoughts and emotions. These thoughts and emotions trigger increased pain by an “amplification” process in the brain. Thoughts and emotions, whether conscious or subconscious, are major factors in producing chronic pain and related syndromes. In addition, stress frequently accompanies these symptoms, such as decreased activity, decreased income, and more difficult relationships, and making the stress-producing pathways stronger. The brain will continue to produce pain because that’s the only way the brain knows how to deal with these stresses. The mind can make the body go through a cycle of very real pain.

People who have unresolved stress in their childhood or in their recent past are more likely to have chronic pain.

Back Pain

M.C.Jensen et al found in 3 separate studies that there was very little correlation between back pain and MRI results. When you take middle-aged people without any back pain and give them MRIs, 64 % of them have bulging discs, degenerative discs, arthritic changes, spinal stenosis, and other common changes. Many people with normal MRI findings have severe back pain. It is critically important to identify 10 to 15% of back pain sufferers with serious problems with imaging studies and clinical examination.

When doctors tell a person there is a physical problem based on an MRI /CT result, the patient immediately believes to have a bad back and behaves as such, and pain is more likely to last longer and becomes more severe. Back surgery may be beneficial for people with clear evidence of nerve damage. But without that evidence, surgery is no better than nonoperative treatment.

There is emerging evidence that treatment of chronic pain with narcotic analgesics can worsen pain, because narcotics can increase nerve sensitization (Mitra, 2008: Silverman,2009).



One enigmatic disorder is fibromyalgia that means “painful muscles and tissues” and people with this disorder has chronic widespread pain throughout their bodies without any pathological process to explain the severe and debilitating pain. Brain imaging studies have shown that the pain is real but it is frustrating for people with widespread pain to have no idea what causes it. Few patients and fewer doctors realize that real pain can be caused by stress and unresolved emotions. People with fibromyalgia also commonly have lower back pain, temporo-mandibular joint (TMJ) pain, irritable bowel and bladder syndromes, insomnia… Biomedical experts have been able to determine that there is sensitisation of pain fibres in the brains and changes of the neurotransmitters in the brains of people with fibromyalgia. There is ample evidence that people with fibromyalgia have much higher rates of stressors and victimization.


Headaches and other disorders

Most people with chronic headaches have normal CT scans and MRIs. However, Mind-Body syndrome can produce almost any imaginable symptoms and even unusual ones such as pain in scars after surgeries and even sensation of unusual smells. These symptoms are likely caused by a vicious cycle of nerve connections that have been learned by the mind and body. Of course, it is common to fear something serious such as cancer, heart disease or other diseases but when the doctor does not know what is causing the symptoms, be relieved rather than worried.


The Brain

Our emotional memories are imprinted in our brain in the amygdala where emotions are registered and stored. The amygdala is closely related to the hypothalamus, the centre for the autonomic nervous system (ANS). The ANS controls our breathing, heart rate, blood pressure, temperature, and other involuntary automatic functions. During time of stress, the amygdala activates the ANS to produce cortisol and adrenaline, which turns on the “fight or flight” reaction. Our protective system kicks in before we have the chance to think.

The ANS controls nerve fibres that affect every area of the body. Studies have shown that emotions such anxiety and anger cause increased tension in the back muscles of those with chronic back pain. This muscle tension occurs without our conscious awareness, can cause real and severe physical pain. Often, we are not aware of the emotions that are triggering these autonomic physical responses (subconscious or unconscious emotions).

Emotional responses increase the activity of the ACC (anterior cingulate cortex), causing pain to become amplified. When the ACC is activated, it turns off the dorsolateral prefrontal cortex (DLPFC), a part of the brain that acts to decrease pain. Chronic stress produces increased sensitivity to pain in the brain, the spinal cord, and the nerves. Certain cytokines are also released causing cells and nerve endings to be more sensitive to pain.

Stress in childhood

Adults who are exposed to traumatic events in childhood such as emotional, physical, or sexual abuse have much a greater chance of developing chronic pain as well as anxiety and other psychological disturbances.


How an injury can start a cycle of pain

Sometimes the pain cycle is started by an injury, such as a strain, a sprain, or a fracture. When the injury occurs, the pain signals in the body and brain get fired. Usually these signals will decrease, and the pain will go away when the injury heals. Many people are suffering from chronic pain from an injury that occurred several months or years ago such as a whiplash injury. Injuries to our body do heal. Even if there is scar tissue, scar tissue doesn’t cause pain. Physical injuries are most likely to create chronic pain if there are stressful life circumstances occurring same time as the injury. If so, the pain signals set in motion by the injury can become learned, and a vicious cycle of pain may develop. The more often nerves fire, the longer the pain occurs, and the more likely these fibres will continue to create this vicious cycle of pain.


Thoughts and Pain

Research has demonstrated how important the brain is in modulating pain. All pain has sensory, cognitive, and affective components. The sensory component includes descriptions of how pain is felt, such as aching, burning, sharpness, numbing. The cognitive component what you think is about the pain, what the cause is, whether you believe is temporary or permanent, controllable, or curable. The affective component consists of your feelings and emotions about the pain, such as fear, anger, worry, and resentment. To eliminate chronic pain, all of the components need to be addressed. The ways in which people think about their pain and the feelings that are connected to it have great impact on the severity of the pain.


Emotions and Pain

John Burns (2006) studied pain thresholds in people with chronic low back pain. He found that when they recalled a time that had made them angry, they had increased activation of the lower back muscles and experienced more pain. Their bodies reacted to anger in a very specific way. Studies have shown that both anger and anxiety can cause a lower pain threshold and can increase muscle tension. Suppression of emotions leads to even higher pain levels.

When pain develops, if we are unsure about the cause, most people begin to worry about the pain. These emotions the trigger pain pathways in the brain to become more pronounced, which, of course tends to exacerbate the pain. A vicious cycle of pain, fear of pain, decreased activity, and worry often ensues. When this happens, chronic pain becomes a way of life, and there is no way out of it it until the thoughts and feelings which are driving the pain are addressed.


The Triggers of Pain

Once a pain cycle is initiated between the brain and body, certain triggers will usually develop and add to the painful responses. For example, if a headache has started during a stressful situation that also happens to coincide with eating a certain food or seeing a certain kind of light. The brain will learn that association and the next time you are exposed to the same situation, the headache can recur. This is called conditioning. Someone with back pain will notice that walking, driving, sitting, or bending over will cause pain, and these actions will be associated with pain and become triggers for pain. Over time, the triggers to the pain will become stronger, and the pain cycle will become very well learned by the brain and the body.


Priming of Pain

When we learn how to ride a bicycle, those nerve pathways become engrained. When we need to, those pathways will be activated, and we will perform that skill even after many years. Nerve impulses that are caused by a physical injury, such as a car accident create a pain pathway between the brain and body, which will typically diminish over a few days or weeks as the damaged tissues healed. Hover, the pain pathways can lie dormant, and at some time in the future, if situations occur creating significant stress and emotions, these pain pathways can re-emerge to create the same type of pain.


Neurologic Mechanism for Mind Body Syndrome

The pathways can begin due to an injury or stressful events that produces strong emotions in the amygdala. Once the pain begins, nerve that send pain signals to the brain sensitive over time and send repeated signals even there is no tissue damage. These signals go to the amygdala and then get amplified by both conscious and subconscious emotions, which trigger activation of the ACC.  The autonomic nervous system (ANS) activates the fight, flight reaction which produces nerve activation, muscle tension, gastrointestinal spasm and cardiovascular activation that worsens the physical symptoms. These pathways get reinforced over time and creates a vicious cycle of pain and increased emotional responses. A variety of triggers (such as certain physical movements, weather changes, foods or situations) can act as conditioned responses and add to the neurologic pathways that perpetuate pain.


How the Brain Stops Pain

The dorsolateral prefrontal cortex (DLPFC), which is in the conscious part of the brain (the frontal lobe), can reverse the vicious cycle of pain by controlling the subconscious pathways that produce Mind Body Syndrome. When the DLPFC is activated, the ACC- the area that exacerbates pain- is automatically deactivated, thus further reducing pain.


Howard Schubiner has developed a program to treat Mind Body Syndrome in Unlearn your Pain.

Other medical books:

The Biology of Belief- Bruce Lipton, PhD

The Mindbody Prescription – John Sarno, MD.