Episode 1: Embrace Uncertainty To Reduce Your Pain

'Stop Chasing Pain' and the Lab of Misfits have collaborated on a number of experiments to understand the sources of chronic pain. Our results show that when people have high pain levels, they also display more intolerance towards uncertainty. This finding asks the question: Is it possible to reduce our sensitivity to uncertainty and would that reduce experiences of chronic pain?

Chronic pain is worse for those who are intolerant of uncertainty.

We asked people where they experienced chronic pain, and, on a sliding scale from 0 to 100, how severe it was. Then they took an ‘uncertainty tolerance’ questionnaire of 12 statements like “I always want to know what the future has in store for me”. The extent to which people agree or disagree with these statements are an indication of how they feel about uncertainty - and hence how tolerant or intolerant they are of it.

After around 300 people had responded, we found a relationship between these two measures: The more intolerant people were of uncertainty, the higher the level of chronic pain they reported. We’re confident that this relationship isn’t just chance, as it passed the usual statistical test that we apply for these kinds of relationships.

What we don’t know is the way the causality runs: Does more pain cause people to be more intolerant of uncertainty? Does intolerance of uncertainty cause people to experience or report more chronic pain? Or is there a third factor (like, say personality) that has a causal influence on both?

Pain isn’t an objective measure of damage

We can speculate on why this relationship might exist though. Like our perceptions of colour, pain doesn’t exist ‘in the world’, our brain makes it up in response to a stimulus in some context, with the aim of creating meaning and directing behaviour. Also just like colour, there is an assumption that it is more objective than it really is. We think that pain is some sensible representation of damage - the more damage, the more pain. But it’s really not like that. Most people will have experienced the situation where they’ve been hurt, but maybe because they’re focussed on something their brain decides is ‘more important’ (like trying to win the race, or make the bus, or whatever) they don’t feel the pain until afterwards. So we’re at least familiar with the idea that pain is not a faithful representation of damage, and context can significantly change the perception of it.

Pain represents perceived meaning

An extreme example of this comes from the reports of athletes competing in the gruelling Tour de France. The race puts the athletes under extraordinary mental and physical stress for several weeks, and riders sometimes fall: a broken wrist, arm or leg (mostly) means withdrawal from the race. Oddly, when this happens the riders describe surprisingly little or no pain, instead they describe relief, even a kind of happiness. As a consequence of the injury, their bodies are no longer required to undergo extraordinary stress for many more days - they can rest up, and their brain recognises the positive meaning of this and responds accordingly - at least in the short term. The broader point is that pain perception isn’t directly linked to damage in the same way colour isn’t directly linked to the wavelength of light, and what the stimulus means to each person will change how that person perceives it.

Pain and uncertainty are deeply intertwined

Uncertainty has a big effect on how pain is perceived. Amazingly, given a choice, people routinely prefer the certainty of experiencing pain to the (uncertain) possibility of experiencing the same pain. Try a thought experiment to see if you feel the same way - would you prefer to press a button a number of times that you knew for sure would give you a small electric shock, or have the button shock you only 50% of the time? Somehow the certainty makes it feel easier to deal with - you’d know it was going to happen, you’d be in control. In fact pain may really be thought of as the brain’s representation of uncertainty rather than damage - think of the greater certainty that the Tour de France rider feels in the moments after they fall.

What can we do about it?

So it makes sense that a sensitivity to uncertainty is likely to predict higher levels of reported pain. Which leads to the question: Is it possible to reduce our sensitivity to uncertainty and would that reduce experiences of chronic pain?

We believe the answer is yes, because there may be an even deeper link: In some cases, chronic pain may actually be caused by a person’s response to uncertainty. For instance, chronic anxiety (in the mind) could be manifest as chronic pain in the body. Such pain, when it has no apparent physical cause, may be the body’s way of expressing the mind’s fear of future uncertainties: A physical expression of mental anguish.

What if we could use this principle in reverse? By increasing your body’s ability to adapt to future unknown challenges by improving its agility, strength and endurance, could you decrease your generalised anxiety and thus your bodily pain that anxiety can create? 

Here’s an intuitive narrative to help embed the point: Imagine Amy and Steve. Last year neither could touch their toes; the furthest they could reach was their knees. Nor could they walk 1 km without resting. In short, their bodies were ill prepared for future unknowns. Now imagine that while Steve remained inactive, Amy committed herself to increasing her body’s agility, strength and endurance. Now after 12 months she can touch her toes, lift items in her house that were previously unmovable and walk to her friend’s home 2 km away without resting. Which means Amy’s body is more adaptable than Steve’s, whose body remains physically unprepared. Of the two, who now is more likely to experience more anxiety about the future? The one whose body is prepared for unknown challenges, or the one who is less prepared? Surely the one who is more prepared for future uncertainty. 

If true, then our suggestion is this: Prepare your body! By increasing the agility, strength and endurance of your body, it will tell your brain “... don’t worry, we’re ready for whatever might come our way”. This in turn will decrease your brain’s generalised anxiety about the future, and thus the physical pain that generalised anxiety can create.

If you haven't taken part in the Map of Pain experiment, you still can. Click here to participate.

Written by: Richard Clarke and Beau Lotto.