Neuroplastic pain
It's real – Even if it is in your head
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This post answers questions from two therapists whose clients were having similar difficulties with pain during intercourse.
Q: I am a clinical therapist working with a woman who has been diagnosed with [list of 24 diagnoses, involving at least 4 organ systems. 24!!]. She is requesting help due to painful intercourse. She lives in the St. Louis, Missouri area. Can you provide a reference, practitioner’s name? She is willing to participate in research.
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Q: I am a pelvic health physical therapist. Your book has been a great resource for me when treating patients who experience pain with intercourse. I often suggest it as a read to patient who are struggling with not being able to have penetrative intercourse. I really enjoy the scientific approach which you took. I am trying to educate myself further but feel overwhelmed at where to go next. Are there any textbooks or journals that you would suggest subscribing to?
A: The book recommendations are at the end! I’m going to rely on readers to put in the comments any providers they have experience with and highly recommend, providers who DO NOT dismiss sexual pain.
But for a more general approach, particularly given the catalog of diagnoses your client has, I want to take this opportunity to talk about the nature of pain.
Since your client has sooooooo many diagnoses, it’s very likely that some part of her pain is not caused by injuries or disease per se, but by neuroplasticity. I know we often hear about “neuroplasticity” as a good thing—and it is! It’s literally your brain learning, adapting, and growing!—but our brains are so plastic, so flexible and adaptable, that sometimes that adapt in a way that makes things worse.
“Neuroplastic pain” is what happens when the brain overinterprets or misinterprets a sensation from a body part. The sensation itself is benign, the kind of signals our body parts are sending our brain all the time and it ignores because it’s not information it needs to do anything about. But the brain, in the case of neuroplastic pain, has somehow gotten the impression that these benign signals are actually signs of danger. The brain receives the information from the body part and decides, “There’s something wrong!”
It’s like if Lassie the dog, on the 50s TV show, was barking at your brain as an invitation to play, but your brain heard the barking and thought, “What’s that, Lassie? Timmy’s in the well???”
And Lassie’s like, “No, Timmy’s fine, I’m asking if you want to play!”
And the brain is like, “OH NO! TIMMY’S IN THE WELL.”
Some of your client’s pain may be caused by existing damage to her body tissues, of course. Sometimes, Timmy is in the well, medically speaking.
And sometimes Timmy has already been saved, Timmy is fine now, but the brain is so tense, so vigilant for any sign that there might be trouble, that it interprets almost everything as a sign of danger.
And that is neuroplastic pain. There is no injury in the body anymore; sometimes there never was. But the brain is so primed for danger, that it creates pain signals in response to body sensations that are not actually dangerous.
The mere fact of your client’s list of 24 diagnoses is itself a warning to the brain that EVERY SENSATION IS A POTENTIAL DANGER SIGNAL WATCH OUT.
There is a common misconception about neuroplastic pain, which is that it’s somehow “not real” because it’s not caused by injury or disease. If we learn that “nothing is wrong” with a body part that hurts, we’re told our pain is “all in our heads.”
Well, duh, ALL pain is in our heads, because that is where the brain is. All pain is created by the brain when it interprets a sensation from the body as a sign of danger. If it hurts, it’s real pain. But if it hurts and there’s no injury, there’s no amount of treating the body part that hurts that will end a person’s pain! Interventions that target the body part might even make the pain worse, because those interventions reinforce the brain’s evidence that there is a serious problem happening in that part and the brain needs to tell the person all about it, all the time.
How do we find out if your client’s pain is related to tissue damage or to neuroplastic overinterpretation of sensation?
There are a variety of ways, but of course first we want a medical exam. If your client gets the good news that “It looks like everything is normal,” hooray! It’s probably neuroplastic pain, which means, we know it can be treated with a combination of physical therapy and education about the nature of pain. Neuroplastic pain is different from pain caused by injury or disease in the body. It moves around and changes when you pay attention to it. It comes and goes, depending on the context. In short, it does not behave the way you would expect pain to behave if it were related to a specific injury or disease in a specific part.
Your role, as her therapist, is to help your client develop awareness of her internal state of stress, depression, anxiety, loneliness, repressed rage (we’ve all got it), and all the emotions we categorize as “negative affect,” and practice skills to move through those states into a state of peace, calm, joy, and connection.
There’s a new, client-friendly book called The Way Out, which will explain how this works, in a way that makes sure the reader never feels dismissed, diminished, or gaslit.
For providers and for big giant brain science nerds, I recommend Explain Pain: Supercharged, which, as the title suggests, explains pain science in supercharged detail.
Questions or comments? Please email my very tiny team at unrulywellness@gmail.com
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Stay safe and see you next time.
