On Emotional Awareness and Chronic Pain

In the previous article we talked about how stress and trauma can feed ongoing pain, even though most people who suffer from chronic pain aren't diagnosed with PTSD.

Today we'll focus on a more common process: emotional awareness / suppression — how it lights up the brain's danger mechanism, and what can be done about it.

What Is Emotional Awareness, and What Is Suppression?

Emotional awareness is the ability to identify and name what I'm feeling ("anger," "guilt," "joy"…). It's an ability that develops with age and differs from person to person.

When emotional awareness is low, a person can experience an emotional state but without full awareness of it — what is sometimes called "emotional suppression."

Neuroscience studies indeed show that during emotional suppression there's a rise in physical stress and an activation of the brain's danger networks (the "danger mechanism"), which can manifest as unpleasant bodily sensations, pain, and other symptoms too. Conversely, when we're aware of our emotions there's a reduction in all of these — that is, a regulation of the nervous system [1,2].

Why does this happen? According to the hypothesis, our brain's job is to constantly try to interpret sensations from the environment and the body, among other reasons in order to classify what's dangerous and what's safe. A round blot with two dots in it will be interpreted as a "face," whether it's real or drawn [3].

Emotions are, in fact, the brain's interpretations of the body's internal sensations, and their purpose is to help us understand them and convey them to our surroundings. When a certain emotion is unbearable, the brain — in its attempt to protect us — may seek a different interpretation for the bodily sensations, such as pain, stress, exhaustion, anxiety, or depression. What all of these share is that they make us take care, rest, stay "safe," or ask for help.

Here's an example: A few years ago I drove a relative and her family to the airport before a flight abroad. Midway through the drive, her young daughter (age 4) started complaining of a stomachache. Her parents, worried about having a sick child on a long flight, tried to figure out what was wrong. Did she eat something bad? Does she need the bathroom? Did we remember to bring medicine?

After long minutes of questions and nonstop complaints, I asked the girl whether she was excited. After all, it was her first flight abroad. She was quiet in response, but her mother jumped on the idea and told her: how natural it is to be excited about the flight… that the plane isn't scary… that they'd see everything from above… that it's even fun… and that Mom would be with her the whole time. After a few minutes the stomachache vanished as if it had never been.

What (perhaps) happened here? In a 4-year-old, an age at which emotional abilities aren't yet fully developed, fear of a possible danger (a flight) is an unbearable emotion. So, in an attempt to protect her, her brain "suppressed" the fear out of awareness, which manifested as a stomachache. The moment she got an interpretation for the emotion (fear of flying), she was also able to get a response to it from her mother (validation and reassurance), and the pain subsided.

The Connection to Stress and Trauma

Just as with the girl, where emotional suppression happened during the anticipation of danger, emotional suppression will usually occur around stressful events. A parents' divorce, the death or illness of someone close, social exclusion, a partner on reserve duty, a breakup, a layoff, a global pandemic, a war that won't end — in all of these the brain may protect against difficult emotions through suppression, which can lead to the development of pain / anxiety / depression or other "unexplained" symptoms.

Moreover, if at a young age we learned that certain emotions aren't "safe," the chance rises that our brain will suppress them throughout life when they appear [4].

For example, if I was raised to believe you must not show weakness, that "only girls cry," or that it's always good to be happy — it's quite possible that later in life, during experiences that raise sadness (a breakup, a death, rejection), the brain will turn to suppression.

Conversely, if in childhood I received messages that if I got angry then people would be disappointed in me, or would be even angrier with me, what will happen later in life when anger appears? When I'm exposed to injustice, to harm, or to an invasion of my personal space? From experience, the brain will try to avoid that authentic anger (whose purpose is to protect me from all of these).

Although suppression can be an effective defense in the short term, in the long term it can lead to an over-flooding of the brain's "danger mechanism," and with it pain and other symptoms.

It's important to note that if it's a single event and there are enough resilience factors in one's life, the effect of emotional suppression probably won't be significant. But — if at that time there's also a physical injury, the aroused "danger mechanism" can leave pain even after it heals.

If there's no injury but there are already dormant "pain cycles" — for example, in the area of an old injury, or an organ I perceive as "problematic" (back / neck) — the brain may identify "ordinary" sensations from that area as dangerous and trigger pain. From here the familiar "pain cycle" can develop, in which the fear of the pain amplifies it, and round it goes, leading to chronic pain.

So What Do We Do About It?

If suppressing emotions amplifies pain, then the reverse process (raising awareness and emotional expression) can help reduce it. And indeed, there are treatments that claim to do exactly that [5]:

Emotional Awareness & Expression Therapy (EAET) — this is a psychological treatment method specific to chronic pain that includes, among other things, practicing the identification and expression of emotions tied to stressful life events. Studies show a significant effect for this kind of treatment on pain levels across a range of chronic pain conditions [6].

For example, in a randomized controlled trial published in 2024, it was found that after EAET about 63% experienced a significant reduction in pain. In addition, over a third of the patients reported a reduction of more than 50% in their pain levels [7].

So do I need to switch therapists?! Not necessarily. Although in Israel (and worldwide too) there are few psychotherapists trained in EAET, from my experience I've seen that in patients who are exposed to this content and do their own work on understanding the emotional causes of pain, their pain level drops. Moreover, if they're already in psychological therapy and share these things with their therapist, the therapy becomes far more effective.

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Recommended links:

• This Might Hurt — a documentary on emotional-expression treatment for recovery from pain
• An interview with Dr. John Sarno on 20/20
• Podcast — a conversation with Dr. Mark Lumley on EAET
• Book — The Mind-body Prescription / Dr. John Sarno

Sources:

Disclaimer: The information in this article is for general knowledge only. It is not personal medical or psychological advice and is not a substitute for it. If you have any health or mental-health concern, please consult a qualified professional to evaluate it.