Chronic pain and the mind: why pain lasts and what helps
Chronic pain is pain lasting more than three months. Pain is produced by the brain as a protective alarm, and in long-term pain the nervous system can become over-sensitive, so pain continues even after tissues have healed. That does not make it imaginary; it means mood, sleep, fear and stress all turn the volume up or down. NICE recommends exercise programmes and psychological therapies such as CBT or ACT for chronic primary pain, and advises against starting opioids like tramadol, which bring tolerance and addiction risk.
Health writers · Aslam Clinic
Chronic pain is pain that has lasted more than three months. It is real pain, not imagined — but it often works differently from the pain of a fresh injury. The nervous system can become over-sensitive, keeping the alarm ringing after tissues have healed, and stress, low mood, poor sleep and fear of movement all turn the volume up. That is why the most effective treatments work on the whole system: movement, psychological therapy and careful use of medicines, rather than stronger and stronger painkillers.
Understanding this is not the same as being told 'it's all in your head'. It is being told how pain works, which is the first step to getting some control back.
How pain works: the brain's alarm
The International Association for the Study of Pain defines pain as 'an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage'. Two words matter: emotional and potential. Pain is the brain's judgement that the body may be in danger, built from nerve signals together with memory, context and emotion.
That is why a soldier may not notice a wound until the fighting stops, and why the same stubbed toe hurts more on a terrible day. Pain is an alarm. Usually the alarm is accurate. In chronic pain, it can become too sensitive.
Central sensitisation: when the volume is turned up
After repeated or prolonged pain signals, nerve cells in the spinal cord and brain can become more excitable. Pain specialists call this central sensitisation. Light touch may hurt, pain may spread beyond the original area, and it may linger after activity. The change is real and measurable — and, importantly, it can be reversed. The same that turned the volume up can help turn it down.
NICE uses the term chronic primary pain when no underlying condition adequately accounts for the pain or its impact, and chronic secondary pain when a condition such as arthritis or diabetic nerve damage does. The two often exist together.
Why chronic pain is not 'all in your head'
- The pain is produced by real nerve and brain activity — it is not invented.
- The mind matters because the brain is where pain is processed, not because the pain is imaginary.
- Psychological treatments for pain work by changing how the nervous system responds, in the same way physiotherapy changes muscles.
- Being offered psychological help does not mean your doctor thinks you are 'mental' or making it up.
Fear, avoidance and the pain–mood loop
Two vicious circles keep chronic pain going. The first is fear-avoidance: pain makes you fear damage, so you avoid moving; muscles weaken and stiffen, weight rises, blood sugar worsens, and movement then hurts more. — 'my back is crumbling, I'll end up in a wheelchair' — feeds the fear. A 2022 analysis of many studies found that these fear-avoidance patterns are linked to greater pain intensity, disability and depression.
The second is the pain–mood loop. Living with pain is exhausting and lonely, and is common. Depression then lowers the pain threshold, disturbs sleep and saps motivation to stay active — which increases pain. The NHS describes this downward spiral directly.
| The loop | A way out |
|---|---|
| Pain → avoid moving → stiffness and weakness → more pain | Graded activity: small, planned increases, even on bad days |
| Pain → poor sleep → lower pain tolerance | Regular sleep and wake times, no daytime napping |
| Pain → low mood → less activity and more focus on pain | Treating depression and planning enjoyable activity |
| Pain → fear of damage → catastrophising | Understanding that hurt does not always mean harm |
What helps: the evidence
NICE's guideline on chronic pain (NG193) asks clinicians to start with a person-centred assessment, to explain that pain may fluctuate and flare, that a cause may not always be found, and that quality of life can improve even when pain does not disappear. For chronic primary pain, it recommends:
| Approach | NICE NG193 position |
|---|---|
| Supervised group exercise programme | Offer |
| CBT for pain or acceptance and commitment therapy (ACT) | Consider |
| A single course of acupuncture, in limited settings | Consider |
| Antidepressants: amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline (adults) | Consider, after discussing benefits and harms |
| Opioids, NSAIDs, paracetamol, gabapentinoids, benzodiazepines | Do not start for chronic primary pain |
| TENS, ultrasound, interferential therapy | Do not offer — no evidence of benefit |
for pain helps you spot and change the thoughts and habits that amplify pain. takes a different angle: rather than fighting the pain, you learn to make room for it and move towards what matters to you — family, work, prayer — even with pain present. NICE notes that antidepressants may help quality of life, pain, sleep and distress even in people who are not depressed; being prescribed one does not mean the doctor thinks you are.
Graded activity and pacing
- Find your baseline: how much walking or activity you can do on a bad day without a big flare.
- Start there, even if it feels too little, and do it every day — good days and bad.
- Increase by small amounts every week or two.
- Avoid 'boom and bust': doing everything on a good day and paying for it for three days after.
- Expect some extra soreness when starting. The NHS notes that becoming more active gradually is unlikely to cause damage, and that in the long term the benefits outweigh any increase in pain.
Painkillers: the limited role of opioids
Opioids such as tramadol and codeine can be useful for short periods after injury or surgery, and in cancer and end-of-life care. For long-term pain they work poorly and bring real risks. The NHS warns that with tramadol:
- The body gets used to it (tolerance), so higher doses are needed for the same effect
- Some people become more sensitive to pain (hyperalgesia)
- It is possible to become addicted, and stopping can cause withdrawal: anxiety, panic, a pounding heart, sweating, aches and poor sleep
- It can cause fits, and is unsuitable for people with seizures or a history of addiction
If you have been taking tramadol for a long time, do not stop suddenly. Speak to a doctor about reducing it gradually; help with is available and confidential.
Low back pain: a common example
Low back pain is the commonest chronic pain doctors see. Most back pain is not caused by serious damage, and staying active is better than bed rest. Scans often show age-related changes that are also present in people without pain, and a report full of long words can itself increase fear.
Chronic pain in Pakistan
'Kamar dard' and 'jor dard' are among the commonest complaints in any Pakistani clinic, particularly in women who spend long hours on housework, floor-level cooking and caring for others. Physiotherapy can be expensive and hard to reach outside cities, and injections and drips are often expected. A pain plan built on daily walking, simple home exercises, sleep and mood care costs little and can be done at home. Namaz and its postures can be adapted — sitting on a chair is permitted when standing is not possible.
When to see a doctor
- New pain, or a change in long-standing pain
- Any of the red flags above
- You need more and more painkillers, or are taking tramadol or codeine regularly
- Pain is making you feel hopeless, or you have thoughts of ending your life — call Rescue 1122 or go to an emergency department if you are in danger
- Burning, numb or painful feet if you have diabetes
Things to try this week
- Write down three things pain has stopped you doing that matter to you. These become your goals.
- Take a short walk every day at the same time, whatever the pain level.
- Keep a regular sleep and waking time.
- Review your painkillers with a doctor or pharmacist, including anything bought over the counter.
- Tell someone close how the pain is affecting your mood — it is part of the pain, not separate from it.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
