Deciphering the Connnection Between Chronic Pain and Anger

She settles herself in the big, comfy chair in my office, and immediately starts crying tears of rage and frustration. I can see that Ruth (not her real name) is angry. "Wow, you look furious! What's been going on?" I ask.

Ruth, 60, starts chronicling the awful week she's had — a confrontation with one of the people she supervises, a pointless but incredibly upsetting argument with her partner, and, the worst, finding out that the promotion she had been expecting had been given to someone else. "I'm just hating everything and everyone in the universe," she tells me.

"I get it," I say compassionately.

During the therapy session, we start talking about some of the things that she's upset about in more depth, and suddenly she lets out a yelp of pain. "Ow, my back! It just started spasming again." Ruth has degenerative disc disease, where the cushioning between the discs in the back has worn away and there is irritation of the sciatic nerve.

According to the CDC, an estimated 51.6 million adults (20.9 % of the U.S. population) report living with chronic pain, defined as persistent or recurrent pain lasting three months or more. Of those, more than 17.1 million live with high-impact pain which substantially affects their ability to work or to participate in daily activities. Anger, even more than depression, anxiety, or shame/guilt, has been found to be the most prominent emotion in people living with chronic pain.

Not all pain is alike. In a 2020 review article in the journal Pain, The International Association for the Study of Pain proposed three subtypes of chronic pain:

Nociceptive pain is characterized by injury to peripheral tissues, such as that experienced with arthritis, cancer pain and other conditions.

Neuropathic pain (also known as nerve pain) occurs when there is a lesion or disease of the nervous system, and is often experienced as shooting, burning, or numbness. Diabetic neuropathy is an example of this.

Nociplastic pain, the most recently conceptualized type of pain, (also known as centralized pain or central sensitization pain syndromes), occurs when the central nervous system processes pain signals abnormally due to alterations in the pain-related sensory pathways. Although X-rays or MRIs show no physical evidence of disease, and there is no clear evidence of actual or threatened damage to peripheral tissues or to the brain or nervous system, this is real, NOT imagined, pain.

Nociplastic pain is the type suffered with by people with low back pain, fibromyalgia, irritable bowel syndrome, pelvic pain and tension headaches. Studies over the years have found a correlation between having high levels of anger and experiencing chronic nociplastic pain. While anger is not the root cause of these disorders, emotional regulation, the ways in which you experience, deal with and express or suppress strong feelings, has been shown to impact pain levels and intensity.

According to Claire Pedersen, PsyD, a clinical psychologist at the Shirley Ryan AbilityLab's Pain Management Center in Chicago and a lecturer at Northwestern University's Feinberg School of Medicine, "The more contemporary approach to treating chronic pain is to recognize the connection between the central nervous system and the rest of the body, and to look at the ways that stress has both a physiological and psychological impact on the way we experience pain."

Anger, which needs to be differentiated from hostility, irritability and aggression, can be assessed by looking at the quality of the anger, the quantity (intensity, frequency and duration of the emotion) and form, which includes how the anger is expressed; physical signs of rage such as clenched fists, choosing to speak, yell or hit, for example.

While anger is a subjective experience, there are several standardized tests that some clinicians use to measure anger-related correlates, with the State-Trait Anger Expression Inventory (STAX-1-2) being the most widely used.

Angry feelings are important whether they are primarily about the fact that you have chronic pain affecting your life in many ways, or if they are also about family, current relationships, jobs and other things. Your anger can affect pain perception, the intensity and frequency of pain, quality of life, the degree of disability and treatment outcome. It can adversely affect relationships with family, friends, employers and health care providers.

The State-Trait Anger theory developed by psychologist Charles Donald Spielberger examines the nature of anger. Pedersen explains, "State anger is a temporary emotional experience in response to a specific precipitating interaction, whereas trait anger is more related to an individual's personality and occurs in response to a neutral situation."

A high level of trait anger in someone with chronic pain causes a hyperactivated state that predisposes your body to quickly move into fight or flight mode. This stress response leads to physiological consequences such as arousal of the autonomic nervous system, palpitations, rapid breathing, increased muscle tension and the release of the hormones cortisol and adrenaline, all of which contribute to increased pain perception.

Individuals with high trait anger tend to interpret situations or people as hostile or unfair. A 2021 review in the Scandinavian Journal of Pain which looked at 38 studies identified several key anger-related variables associated with pain-related outcomes and found significant correlations with feelings of perceived injustice.

People deal with anger and other stressful emotions in one of two ways. Those who suppress anger or direct it toward themselves use an anger-in approach. Anger-out people direct their anger toward others or towards their environment in a very expressive way.

While being over-expressive or inappropriately angry can cause repercussions in your work life or personal relationships, people who rarely acknowledge or express their anger in a modulated way tend to hold it in until, "like a bottle with a carbonated beverage, it builds up and eventually explodes or spills over, causing an exacerbation of both physical and emotional pain," Pedersen says.

According to the National Center for Post-traumatic Stress Disorder, approximately 15% to 35% of chronic pain patients also have PTSD. One study found that 51% of individuals with chronic low back pain have PTSD symptoms. Survivors of emotional trauma or physical, psychological or sexual abuse tend to be more at risk for developing certain types of chronic pain later in their lives.

Emotional regulation is the process which intensifies, mitigates or maintains the strength of the emotional reaction. Learning to deal with anger in healthy ways can normalize activity in the brain's medial prefrontal cortex and amygdala. This leads to decreases in both state anger and trait anger, with an ensuing lessening of pain severity. Clearly, whether you are an anger-in or anger-out kind of person, learning to manage and express a range of emotions can lead to more gain, and, hopefully, less pain!

Learning to express emotions and communicate needs in an assertive way while maintaining appropriate boundaries has been found to be correlated with pain reduction. There are a number of therapies that have been proven helpful to people living with chronic nociplastic pain.

Cognitive behavioral therapy and Acceptance and Commitment Therapy are the gold standards of psychological treatment. Dialectical Behavior therapy, an offshoot of CBT, helps individuals to manage challenging emotions. Relaxation training and mindfulness are useful in turning off the stress response, Pedersen says, and "diaphragmatic breathing gives signals to the body to relax, lowering the level of tension that is being experienced."

Emotional Awareness and Expression Therapy is a relatively new type of psychotherapy, particularly useful for those with post-traumatic stress disorder, that helps them to face and process the traumas and psychological conflicts that they have been blocking and to learn healthy ways to express emotions.

According to Pedersen, "Our natural reaction is to want to avoid feeling unwanted sensations or emotions. But, pushing these down repeatedly doesn't work, and eventually they will pop up and (metaphorically) hit you in the face." She suggests learning emotional regulation and anger management skills that you can incorporate into your daily life, such as:

• Identifying and labeling emotions. “If you name them, you can tame them.”
• Increasing your repertoire of behavioral responses following an emotional upset, whether it’s calmly expressing feelings, taking some deep breaths, temporarily walking away, or distracting yourself with more pleasant thoughts
• Building a social network and a support system, including a therapist if needed
• Reconnecting with your own values, clarifying what’s important to you and re-engaging with life in a meaningful way in spite of chronic pain
• Problem solving and cognitive reappraisal or reframing

"Our brains and bodies communicate in beautiful and intricate ways," says Pedersen. "Even when living with chronic pain, we can use that connection to promote physical and emotional well-being."

Barbra Williams Cosentino RN, LCSW, is a New York-based psychotherapist and writer whose specialties include chronic illness, health, aging and parenting. Bylines include HealthCentral, the New York Times, Today's Geriatric Medicine, Forward Magazine (Fox Chase Cancer Center), BabyCenter and many others. Read More