What happens when emotional pain becomes physical? Dr Anchita Karmakar and clinical pharmacist and PainWISE Director Joyce McSwan explore this concept.

When Dr Karmakar lost her daughter, abducted by the child’s father and taken to a foreign country, it began a decade-long quest for justice.

‘As a parent you never imagine that someday, you will not be able to see, hug and love your beautiful children,’ she said. ‘You assume that you will watch your children grow up, go through their milestones and ensure that they have the best shot in life with the support and love you provide for them.’

Dr Karmakar and Ms McSwan have a close working relationship, with Dr Karmakar often referring patients to PainWISE. But unbeknownst to Ms McSwan, Dr Karmakar was suffering from pain of her own.

At one point in her journey, Dr Karmakar began to experience tangible, debilitating physical pain in her hand. After having a series of tests including X-Rays for conditions such as carpal tunnel syndrome, no underlying physical causes for the pain were unearthed.

‘We were rather perplexed by her pain condition, because it wasn’t caused by anything physical as such. It turned out that it was actually emotional pain that turned into physical pain,’ Ms McSwan said.

How the pain manifests

According to Ms McSwan, the progression of this type of pain is insidious. ‘People will complain of a pain of some kind – it could be whole body or limited to a certain limb,’ she said.

‘It has to do with how our brain expresses pain and the regions in the brain where this occurs and more importantly how our brain is massively connected with the rest of the body as a single entity. What has to be acknowledged here is that there are direct neural connections between all our body systems and each feedback and modulate the other. Whether we allow ourselves to be aware of it or not, the psychobiological connection is there and ongoing. And the expression of pain is real.

‘Pain is truly very complex. The neural, blood, and immune pathways between brain and body are tagged with body location information in the somatosensory part of our brain. The involvement of our communication pathways of the spinal cord, brain stem and thalamus, continues to add layers of complexities until the pain experience becomes conscious and grabs our attention. Our nervous system is a true marvel,’ Ms McSwan said.

‘Pain is protective for our survival so this alert can maladapt to stay on high alert.  The nervous system, brain and body is just doing the job it is designed to do. And what we have to do is acknowledge that it is there, feel the pain (even if it is unpleasant) and seek treatment supportively to be able to help our system to modulate back again. There are many techniques these days to help with that.’

Ms McSwan said that the typical investigative routes of pain, such as MRIs and X-rays, will not reveal the underlying cause.  She said it’s imperative that investigation extends beyond these limited methods.

‘We have to talk to the patients and look at the pain in a broader context, such as finding out when it began and some history of what kind of things were happening around the time the pain response started.

‘In Dr Karmakar’s case, we couldn’t see anything in the conventional tests, but the pain was incredibly real. On the hand she had the pain in, she used to wear a ring associated with her daughter. So, the emotional pain was expressed in that hand, almost to the finger that she wore it on,’ Ms McSwan said.

Once they worked out that it was emotional pain, the underlying trauma needed to be dealt with through therapy. Dr Karmakar’s recovery is ongoing, but she has healed through writing the book – and proven that despite the distress and despair she experienced, she could use the pain for greater good. She hopes it will help others who are faced with emotional pain that presents physically to be validated, acknowledged and assisted without judgement, Ms McSwan said.

Working together

Ms McSwan said that it’s important for doctors and physicians to collaborate through patients, and that in her experience, doctors appreciate the support in their understanding of pharmacology and pain management. It is simply impossible to manage such complex care needs on their own.

‘If they know your intention of care, they value that support. It’s vital to communicate – but it takes an investment of time and effort to cultivate these relationships,’ she said.

It all comes down to picking up the phone and figuring out the best way to communicate in order to express a concern, Ms McSwan said. When faced with a patient that has complex care needs, she recommended asking them who their doctor is so everyone involved in their care can be on the same page and can express any concerns. The initial effort expended saves time in the long run.

It’s equally important to bear in mind that pain is subjective, and that’s it’s vital to listen to patients, she said.

‘There are some good assessments that we as pharmacists can do – for example, asking patients about daily function, their barriers and their limitations. Before long, you will get a good idea of how pain is affecting their lives. If they say they have been screened and nothing indicates a reason for the physical pain, that’s when it’s time to help them unpack some of their thoughts and emotions about the pain experience.’

Assessing the ‘yellow flags’ will highlight some important aspects of the patient’s beliefs about their pain. Catastrophisation or rumination, for example, will slow down healing process, Ms McSwan said.  

She also said that it’s important not to judge, but to be empathetic, and recommended finding a psychologist that they can collaborate with and link the patient to. Patients who are taking analgesics for their physical pain will achieve so much more when it is combined with emotional support. Through the rapport pharmacists have with their patients, they can really help to facilitate the patient’s confidence to engage with this support.

‘Being able to use the right language to help the patient understand their pain is vital. Rather than saying, “I think you need to see a psychologist for your pain”, which can send the wrong message that you think their pain is in their head, perhaps let them know that the way they think about their pain can affect how they experience their pain. A psychologist can teach them some helpful tools on how to influence this.’

For further information on pain management, pharmacists can refer to PSA’s Chronic Pain MedsCheck CPD modules (Identifying patients and Using a chronic pain MedsCheck).

Joyce McSwan and Anchita Karmakar have authored the book, ‘With or Without your Smile’.