Sad, not happy

Question from health professional: “How do you feel?”

Answer from me: “Sad… not happy”.


Pain is multidimensional. The experience of pain is not generated from physiological processes alone. Considering the multidimensionality of pain is especially important for both 1) understanding why chronic pain has such a large impact on peoples’ lives, and 2) for developing effective pain management for each person.

There are many models of pain that try to capture the varied dimensions of pain. In biopsychosocial models (1), there are sensory, affective, cognitive, and behavioural dimensions1. There are many variants of biopsychosocial models so I’ll outline the general way these dimensions are described.

The sensory dimension is the “pain” part of the pain experience. This includes physiological processes and systems, such as activation of nociceptors (free nerve endings in our periphery which are sensitive to heat and cold, pressure, or chemicals).

The cognitive aspect is the thoughts or “cognitions” about pain that a person has. For example, not being able to stop thinking about pain.

The behavioural dimension is the action or inactions associated with pain. For example, avoiding certain movements.

The affective dimension is the emotional feelings a person with chronic pain may have about their pain. For example, feeling scared that the pain might never go away.

These dimensions do not occur in a vacuum. A person lives in a social environment: family, friends, work, communities, countries. These social environments affect the immediate sensory, cognitive, behavioural and affective dimensions too.

Here’s a simplified biopsychosocial representation of my pain experience in context.

To explore the importance of considering chronic pain in a biopsychosocial context start with the articles the Biopsychosocial Model Helps Explain Complex Differences in Pain and The Experience of Chronic Pain: Many Dimensions, Lots of Uniqueness.


I’m going to give a personal example to illustrate the importance of considering the affective dimension in pain management.

In 2012 I was assessed by a group of health professionals at a Pain Management Clinic. I was in the midst of the worst flare up of my fibromyalgia that I had experienced (and is still the worst I have had). When I went to the Pain Management Clinic, I did not know a lot about pain or pain management.

One of the concerns identified in this assessment was that I could not name my emotions. When asked how I felt, I could only reply “sad” and “not happy”, which to any person seeing me would have seemed like a huge understatement.

At this point in time, my pain was out of control, I was taking large amounts of codeine, taking other medicines to manage the side effects of taking so much codeine, and the one way I knew how to cope – pushing my pain aside until later – had stopped working. I was deeply depressed. I had resigned from my job and was basically spending most of my day in bed. And all I could say, was “sad” and “not happy”.

When I was then asked just to name emotions, I couldn’t even write a list. This was quite shocking to me. My honours and masters research in psychology had been on emotional language. I had spent hours thinking, reading, and writing about emotions. Yet, I could not list emotions. There are quite a lot of emotional feelings or states!

Happy, sad, angry, fearful, surprise, disgust are basic emotions, and then there are all their nuances; delighted, distraught, steaming, terrified, shocked, revolted to name a few. And all I could say, was “sad” and “not happy”.

Alexythimia describes this inability to name emotions you are experiencing or that are being experienced by others.

At the end of this first visit to the Pain Management Clinic, I had learned that it wasn’t just the sensory dimension of pain that was stopping me from managing my pain and living my life. All dimensions of my pain needed to be addressed.

It is easier to change some dimensions than others. Thoughts and behaviours are the easiest (though by no means easy!). In the next pinch, I’m going to give a personal example to illustrate the importance of considering the cognitive dimension in pain management.


[1] Some biopsychosocial models have three dimensions.


  1. Asmundsen, G. J. G. & Wright, K. D. (2012). Biopsychosocial approaches to pain. In T. Hadjistavropoulos & K. D. Craig (Eds.), Pain: Psychological Approaches (pp. 35–57). New York: Psychology Press.

Thoughts (2)

I drafted this pinch on my phone one evening. I’ve left the first half as I wrote it in the moment.


Pain in the moment

It is 6.20pm on a Tuesday evening and I’m struggling.

My pain has flared up over the last week. I’m stuck in a loop where I’m sore so I’m not sleeping well, but not sleeping well makes the pain worse, which means I’m sore so I’m not sleeping… aargh sums up the frustration.

I’m in bed already. I’m trying to focus on a thought which was key to a shift in how I managed my pain.

At the Pain Management Programme, I was introduced to this thought: it is not my job to deal with any future pain, it is only my job to deal with the pain in this moment.

I used to panic when I felt this level of pain. I would spiral into thinking: how am I going to cope if this never eases? How will I have any life? How will I work?

All that worry took a lot of energy. It certainly didn’t help me manage the pain!

Dealing with the pain in this moment is a type of mindfulness.

Mindfulness practice/meditation

“Mindfulness” doesn’t only refer to one thing. There are lot of aspects to mindfulness and many ways to be mindful. People practice mindfulness for many reasons. One reason is to help manage pain.

Researchers measure whether mindfulness practice is effective for pain management by asking about changes in pain or other quality of life factors. In some studies, some types of mindfulness seem to improve some measured outcomes1,2. There’s still a lot we don’t understand about mindfulness and pain management.

As with all strategies for pain management, it is about finding what works for you. If mindfulness doesn’t work for you, don’t do it. If some parts work for you, just do those.

Being aware of my pain and trying to let it, and the emotions and thoughts that accompany it, go by without judgement, is really not for me! I tried for a few months but I find this type of practice makes me more distressed.

Focussing on my breathing helps me to lose some of the tension associated with my pain.

Reminding myself that I am here in this moment and I only need to manage the pain is this moment, not in a minute, or in an hour, a day, a week, a month or a year helps a lot.

So, I’m here dealing with the pain only in this moment.


1. Minding mindfulness – what is going on? https://relief.news/mindfulness-breathing-pain-and-fibromyalgia/

2. Does mindfulness improve outcomes in chronic pain patients? https://relief.news/pain-mindfulness/


If you’re interested in learning more about mindfulness practice/meditation for self-management of pain, this page is a great place to start.

Fibromyalgia (1)

I planned to make this post live on Friday. However today, Tuesday 12th May, is Fibromyalgia Awareness Day. The topic seemed appropriate.


My chronic pain has the diagnosis fibromyalgia.

I can see that I’m going to write many pinches about fibromyalgia as this is my pain condition. I’ve labelled this pinch “fibromyalgia (1)” as I don’t know how high the numbers will go.

In this pinch, I’ll give a glimpse into what led to the start of my pain management journey – from when I first began experiencing pain that persisted to when I was diagnosed with fibromyalgia.

The author stands next to a path by the sea. The path continues off into the distance.
My pain management journey is long and winding.

Getting the diagnosis, the syndrome itself, and my experience day-to-day of having fibromyalgia is complicated. Neither the diagnostic process, the syndrome, or the day-to-day experience of having fibromyalgia is well understood.

Growing up, I had several chronic pain experiences: temporomandibular joint (TMJ) disorder starting at 10 years old, with many years of uncomfortable dental treatment (a series of plates to expand, then stabilise, my jaw); repeated kneecap (patella) dislocations starting at 11 years old, culminating in surgery when I was 16; and carpal tunnel syndrome in both hands starting at around 15 years old (surgery when I was 17).

These were painful experiences, and chronic in that the pain persisted for more than three months. I still have residual effects, including pain, in my jaw, knee, and wrists. I didn’t have widespread pain though, pain beyond the specific areas that had healed tissue damage, until I was 18 years old, in 2005.

I started feeling sore all over, all of the time. This was new. The pain was confusing. The deep achy and burning sensations moved around – I wasn’t sore in the same place all of the time. The symptoms that came with the widespread pain were new too – debilitating headaches, general feeling of being unwell (like the beginnings of a virus), low grade fevers (around 38 degrees Celsius), and brain fog.

Brain fog is a colloquial term for cognitive dysfunction in attention, memory and decision making (1, 2). Fibro fog is brain fog specific to fibromyalgia.

“Brain fog” captures the feeling of your thoughts being fuzzy. It can be incredibly hard to think. For me, when I have brain fog, I struggle to find the words I want to say. My usually quick thinking, questioning brain seems to grind to a halt. It’s an effortful struggle to follow a plot in a book, or even a conversation.

I also experienced hyperalgesia and allydonia.

I didn’t know the terms for these experiences but they were signs that something had changed in how my brain and body were processing, and interpreting, signals of nociception (of danger to body-tissue: heat and cold, pressure, and chemicals1) and touch.

This diagram below shows the relationship between how intense a stimulus is (e.g., pressure or heat) and the reported level of pain (here on a scale from 1 to 10). The diagram shows a change in sensation for the same level of stimulation as a result of injury.

A figure depicting the change in in the relationship between stimulus intensity and pain sensation
Downloaded from: https://www.sciencedirect.com/topics/medicine-and-dentistry/allodynia
Adapted from Cervero F. & Laird J. M. (1996). Mechanisms of touch-evoked pain (allodynia): a new model. Pain, 68, 13–23.

Pain threshold is the level of stimulation required to feel a sensation subjectively labelled as “painful”.

This figure shows that as stimulus intensity increases, reported pain sensation increases as well.

After injury, or as part of developing a chronic pain condition, the level of stimulation that results in pain is lower (shifted to the left in the figure).

Hyperalgesia describes the phenomenon where something that usually hurts a little, hurts a lot. Bumping into a doorway hurts a little (well depending on how hard you do it!), but for me it can feel like I imagine it would if someone took a hammer to my arm.

Allydonia describes the phenomenon where something that doesn’t usually hurt, hurts a lot. Your clothes sitting against your skin is usually unnoticeable, but for me it can be not just noticeable but painful.

Over more than a year, I went with my Mum to my GP, to various specialists, and finally to a Rheumatologist to try to find an answer to the scary, strange, unpredictable, collection of symptoms I was experiencing.

A Rheumatologist is a medical professional specialised in understanding and treatment of autoimmune (impaired inflammation response) and musculoskeletal conditions such as the varieties of arthritis, lupus, and fibromyalgia.

Along the way I had a lot of tests! I’d had some earlier when I had carpal tunnel syndrome. It is unusual for someone so young to show evidence of nerve damage in nerve conduction tests – so I’d had an MRI to rule out Multiple Sclerosis (MS).

To sum up the tests, thankfully there seemed to be nothing physiologically wrong with me. Yet something was evidentially wrong with the amount of pain I was experiencing.

The Rheumatologist diagnosed fibromyalgia by 1) ruling out MS, lupus, forms of arthritis, and many other autoimmune and musculoskeletal conditions; and by) testing for tender points.

I didn’t have any signs of any other conditions, and I was sore when touched in many of the 18 tender points. In my final appointment, my Rheumatologist told me I had fibromyalgia and sent me away with a leaflet about it.

The leaflet was produced by Arthritis New Zealand and was an older version of this leaflet2.

So, my diagnosis process ended with me being sent away with a leaflet. My pain management journey started there and is an ongoing process.

Spoiler alert, there were some very hard times ahead. Especially in 2012. To be continued in fibromyalgia (2)….


[1] Nociception will have its own pinch at some point.

[2] Arthritis New Zealand are a wonderful organisation. They support people to manage their arthritis and pain, and raise awareness about different forms of arthritis. I have attended informative sessions about fibromyalgia and pain management run by their educators. Their Facebook groups connect me to other people with pain.


  1. McCracken, L. M. & Iverson, G. L. (2001). Predicting complaints of impaired cognitive function in patients with chronic pain. Journal of Pain and Symptom Management, 21, 392–396. https://doi.org/10.1016/S0885-3924(01)00267-6
  2. Moriarty, O. & Finn, D. P. (2014). Cognition and pain. Current Opinion in Supportive and Palliative Care, 8, 130–136. https://doi.org/10.1097/SPC.0000000000000054

Thoughts

One of the key changes in the way that I think about my pain that resulted in great improvements in how I manage my pain is:

Chronic pain is my brain and body being really, really, really good at protecting me.

I was first introduced to this way of thinking about pain at the Pain Management Programme I attended in 2013.

I was never interested in knowing more about pain, or about my pain, before this programme.

I was certainly not interested in studying or researching pain! Why on earth would I want to learn more about something that was such a negative being in my life!?

Turns out understanding pain is a powerful tool in your pain management toolkit and that there are a lot of unanswered questions about pain. For my PhD, I tested if an impairment in attention might be one reason that pain makes it so difficult to think. That’s another story for another pinch or more another time.

Pain is produced when your brain detects threat to body tissue. One of the best explanations of pain I’ve seen is this talk by Lorimer Moseley.

In chronic pain, there is either ongoing damage to body tissue, or your threat protection system has become overactive and detects threat when there is none (1, 2, 3).

Many factors go in to the assessment of threat: including your previous experience (as with Lorimer and the pain he experienced from a scratch from a branch in the video), the context of the current situation, even your knowledge of pain (1, 2, 4).

Detection of threat is not under your conscious control, but one thing that is possible to change is how you think about and respond to the pain. I’m not saying this is easy. I’ve been practicing thinking that of my pain as my “overactive threat protection system” for years. It doesn’t always help me, and sometimes I still hate my pain.

The more I practice thinking about my pain this way though, the more I don’t feel overwhelmed by the pain.


  1. Moseley, G. L. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews, 12, 169–178. https://doi.org/10.1179/7108331907X223010
  2. Moseley, G. L. & Jones, L. (2009). Pain. In S. Kumar (Ed.), Ergonomics for Rehabilitation Professionals (pp. 71–102). Boca Raton: CRC Press.
  3. Tabor, A., Keogh, E., & Eccleston, C. (2017). Embodied pain – negotiating the boundaries of possible action. Pain, 158, 1007–1011. https://doi.org/10.1097/j.pain.0000000000000875
  4. Peters, M. L. (2015). Emotional and cognitive influences on pain experience. In D. P. Finn & Leonard, B. E. (Eds.). Pain in Psychiatric Disorders. Modern Trends in Pharmacopsychiatry (Vol. 30, pp. 138–152). Basel: Kager. https://doi.org/10.1159/000435938