Chronic fatigue, Pain amplification, Sensory amplification, Tension, Stress, Fibromyalgia, Irritable Bowel Syndrome, Musculo-Skeletal Pain Amplification Phenomenon (MSK-PAP)

Protective Physiologic Reactions: A Hypothesis Regarding Chronic Fatigue and Pain Amplification

By Rob Rennebohm, MD

This document is intended to help patients and families better understand how musculoskeletal pain (even extreme pain), or chronic fatigue (even profound disabling fatigue), or both pain and fatigue, might sometimes be due, at least in part, to “protective physiologic reactions.” It represents just one way of understanding chronic fatigue and musculoskeletal pain. Please understand that the concepts presented represent a hypothesis, rather than proven fact.

Many people, including children, experience what I prefer to call a “chronic fatigue/pain and sensory amplification” disorder—a disorder that, I hypothesize, represents a complex set of protective physiologic reactions to chronic physical tension, emotional tension, or both. This set of reactions is intended to get our attention, get us properly attended to, and encourage us to reduce the unhealthy tensions that our physiology has sensed. It is an example of a way in which our “body speaks to us.”

Normally, our human physiology hums along silently, as it takes care of our body’s needs. It silently maintains and regulates our blood pressure, heart rate, body temperature, digestion, and our autonomic nervous system, etc. It also lets us know when we have been physically injured—by sending appropriate pain messages to our consciousness.

Our human physiology is very protective, sensitive, and wise. It is beautifully designed to be that way, and we should be thankful for this.

Our human physiology cares about us. It senses when we are tense—physically, emotionally, or both. It senses when we are physically bracing ourselves to meet the usual challenges of everyday life, as well as unusual challenges. It senses our emotions—when we are unsettled, uncomfortable, un-relaxed, ill-at-ease, worried, fearful, confused, frustrated, tense, overly intense, anxious, stressed, overwhelmed, resentful, demoralized, dispirited, disheartened, feeling helpless, feeling hopeless, or feeling as if we are “not measuring up” (to our own expectations, to the expectations of others, or to both), or feeling bad about ourselves. It becomes particularly concerned when it notices that such physical and/or emotional tension is chronically present. It does not want us to go through life, chronically, carrying such tension. It does not like to see physical or emotional unrest (which often go hand-in-hand). It prefers to sense that we are emotionally and physically relaxed, at ease. It wants us to feel good about ourselves. It wants us to be at peace—with ourselves and our surroundings.

In addition to sensing emotional and physical tension, our human physiology senses and reacts to whether we are getting enough exercise and whether we are sleeping well. It does not like to see us not using all our muscles and the full range of motion of our joints. It worries when it senses we are not invigorating our hearts. It knows when we are not descending into sufficiently deep and restorative sleep. When it senses these disturbances, it assumes that something might be wrong and might need attention, including medical attention.

Our human physiology is pretty smart. It is constantly monitoring us, for our own good. It is very sensitive and not easily fooled. It senses disturbance before we may be conscious of it. Just as we, as human beings, tend to worry, our human physiology tends to worry and is programmed to react to perceived disturbance.

It is important to realize that there is a spectrum, regarding how sensitive, reactive, caring, and smart peoples’ human physiologies are. Some people have very sensitive and/or very reactive physiologies; others have quite insensitive and/or unreactive physiologies. Everyone is different in this regard. (More on this later.)

Our human physiology wants to protect us and is programmed to do so. When it senses chronic emotional or physical tension, it wants to let us know of its concern. It wants to get our attention, in hopes that its signals to us will lead to remedy of whatever is causing the tension. It wants to force change for the better. It feels the need to change the status quo. It does not want to simply provide symptomatic relief, by pouring out endorphins or other substances that would make us feel good. That would be too easy, would cover up the problem, would not encourage us to address the root causes of our tension, and would violate our free will.

Our human physiology has limited but very good ways to signal its concern, safely get our attention, and force corrective action. Kindly, it does not want to get our attention in ways that could cause bodily harm. Two good ways to safely get our attention are to create fatigue and to amplify pain (and/or sensation). If our human physiology makes us feel profoundly tired, it becomes difficult for us to keep going through life the same way we have been. If our physiology amplifies pain so that we are suffering from musculoskeletal misery or chronic headaches or frequent abdominal pain, that pain makes it difficult for us to keep doing what we have been doing. (Pain amplification occurs within the brain itself. Please see the section entitled MSK-PAP for a more detailed explanation of how “pain amplification” might occur.)

The profound chronic fatigue (often totally exhausting), or the pain amplification, or both, force us to take stock and take some sort of corrective action. At the very least, these symptoms force us to realize that something is wrong and to ask “what’s wrong.” Usually, these symptoms prompt (sooner or later) a visit to a physician, who then, ideally, helps us to accurately figure out “what is wrong.”

A good physician will consider all plausible explanations for “what is wrong,” including combinations of causes. The list of plausible explanations includes all of the diseases that can cause chronic fatigue (and/or pain) but also includes the possibility that the fatigue or pain could, at least in part, represent a protective reaction on the part of our human physiology. Subsequent investigation is designed to clarify “what’s wrong.” Is it one of the plausible diseases? Or, at least in part, is the person experiencing a protective physiologic reaction(s) that is causing profound, very real, even disabling, fatigue and/or pain?

Ideally, if the fatigue (or pain) is, at least in part, due to a protective physiologic reaction, the physician will recognize such and will effectively explain this phenomenon to the patient. Misdiagnosis, either way, does no good. If the fatigue is largely or completely due to a protective physiologic reaction, it is counter-therapeutic to erroneously or unconvincingly attribute the fatigue to a specified or unspecified disease process. Misattribution just causes more mystery, confusion, worry, fear, frustration, resentment, unrest, and tension—the very kinds of emotions that, in fact, prompt and fuel our human physiology’s concern and protective reactions. Likewise, it obviously does no good to attribute the fatigue to a protective physiologic reaction if, in fact, it is due to a specific disease process, such as an autoimmune disease.

Also, good is limited if, after thorough investigation for plausible diseases, the physician declares that he/she could find “nothing wrong” and ends the patient-physician encounter on that only half-reassuring, half-helpful, and only half-correct note. Even worse would be an incomplete investigation, followed by the expressed or implied insinuation that the problem is “all in your head,” followed by no further effort to explain matters or help the patient, who is now left bewildered and alone, to fend for herself/himself. Even if the physician correctly determines that the “what’s wrong” is a protective physiologic reaction, good is limited if the physician does not fully explain this phenomenon to the patient and does not discuss how to reverse the reaction.

How does one reverse protective physiologic reactions? The short answer is to eliminate or, more realistically, diminish or cope better with the very tensions (physical and/or emotional) that one’s human physiology is appropriately reacting to in the first place. The protective reaction will decrease or cease only when our human physiology senses that unhealthy tensions are trending in the right direction, such that there is less for our physiology to be concerned about. The protective reaction diminishes only when our human physiology becomes convinced that unhealthy tensions are being adequately addressed, such that it can consider its job (of protecting us) to be done. If it sees no progress, it will continue to express its concern (through persistent creation of fatigue, pain amplification, or both). Our human physiology is not easily convinced that its job has been done. It cares too much and is too smart to allow itself to be falsely reassured. It needs lots of convincing. The longer answer includes the following.

The first step is an educational, intellectual one. The patient needs and deserves to fully understand the concept of “protective reactions on the part of our human physiology.” Knowledge empowers, inspires, and frees. Without this understanding, the patient is left confused, sceptical, un-empowered, and ill-equipped to do what is necessary.

The above education is of limited value, however, if the patient does not believe the concept being explained, is not convinced that the concept applies to his/her situation (assuming it does), or is still worried that some disease process is being missed.

So, the education needs to be both understood and trusted—but only if it deserves trust, of course.

Often, successful education goes a long way in helping the patient to reverse the fatigue/pain amplification reaction and the vicious cycles that often accompany it. The emotional relief that this clarifying education provides can help turn things around, sometimes greatly so. The new understanding can largely reduce, even eradicate, the fears, mystification, confusion, worry, frustration, and resentment that build when it is unclear “what is wrong.” Education is freeing.

The next step is to create a list of the life situations or life thoughts that seem to create the most physical and/or emotional tension. The patient needs to identify those things or feelings going on in their lives that make them the most uncomfortable, un-relaxed, stressed out, tense. Sometimes, the number one “stressor” is the just mentioned confusion, mystification, fear, frustration, and resentment associated with having symptoms and not knowing “what’s wrong” and not receiving effective help in fully determining and understanding “what’s wrong.” Often there are other underlying stressors. Creating a list requires honesty, courage, and objectivity. Sometimes patients, by themselves, can figure out what belongs at the top of the list. Sometimes parents or friends need to help. Sometimes the help of an objective and skilled psychologist/counsellor is needed.

Once these top stressors are identified, the next step is to determine how best to either eliminate, diminish, or better cope with these stressors, starting with the biggest culprit. Some ways of coping are unhealthy; other ways are much healthier.

The next step is to break into and disassemble the various vicious cycles that tend to evolve during the development of a chronic fatigue/pain amplification disorder—as in the following examples.

Exercise: When a person is chronically tired or chronically achy or both, they tend to not feel up to exercising. We rely on a certain amount of gently invigorating physical exercise to generate natural energizers and natural pain killers to help us through an ordinary day. It is a disadvantage to go through each day with suboptimal levels of natural energizers and natural pain killers. These low levels increase our fatigue and pain, thereby contributing to the vicious cycle. We can break into that vicious cycle by gradually getting more exercise, in moderation, in the best way our circumstances permit.

Sleep: During good quality sleep, natural energizers and natural pain killers are generated to help us get through the next day. If we are not getting good quality sleep, we go through the next day with suboptimal levels of natural energizers and natural pain killers—which may already be low because of lack of invigorating exercise. This makes us even more tired and achy—thereby contributing to a vicious cycle.

Furthermore, without adequate exercise, we are not as pleasantly tired and relaxed at bedtime; so, we do not sleep as well. And, without good quality sleep, we do not feel up to exercising the next day. This is how vicious cycles develop, which make the chronic fatigue/pain amplification even worse. By breaking into these vicious cycles, the chronic fatigue/pain amplification can be decreased in intensity. The way to break in is to develop a gently invigorating exercise program that avoids the extremes of no exercise and exercise that is too much, too soon. The other component of breaking into these vicious cycles is to work on sleep hygiene.

Emotional stress can also accelerate these vicious cycles, in part by interfering with sleep. So, again, it is often important to identify and effectively address emotional issues.

Nutrition: Good nutrition can also help to break into vicious cycles and restore balance.

Successful treatment of a chronic fatigue/pain amplification disorder, therefore, requires a comprehensive approach—paying attention to all of the concepts mentioned above. In addition, there is sometimes a role for temporary use of various medications, such as gabapentin, Lyrica, anti-depressants, or sleep aids. These medications can provide temporary symptomatic relief, while the patient works on the underlying root causes of their physical and emotional tension. Such medications are simply options and are often not necessary.

The good things about a “chronic fatigue/pain and sensory amplification disorder” are that it is completely reversible, causes no bodily harm while it is present, and makes you a better person afterwards (once you have recognized it for what it is and have successfully made the needed healthy changes). In that sense, it is a kind, wise, protective, caring set of physiological reactions, designed to help you.

As stated earlier, it is important to realize that some people have human physiologies that are very sensitive, very reactive, and very “worrywart-ish,” while other people have human physiologies that are not very sensitive or very reactive. Sociopaths, for example, have quite insensitive and unreactive physiologies. That is why sociopaths can pass a lie detector test, even when they have just lied. There is a spectrum, regarding how sensitive, reactive, caring, and smart peoples’ human physiologies are. That is why one person, who is dealing with only an average or below average amount of tension, might develop a chronic fatigue/pain and sensory amplification disorder, while another person, who is dealing with extraordinarily great stress, does not develop a chronic fatigue/pain and sensory amplification disorder. It is people with particularly sensitive and reactive physiologies who are most likely to develop a chronic fatigue/pain and sensory amplification disorder. So, it is not so much the level of tension/stress that determines whether a chronic fatigue/pain and sensory amplification disorder develops; it is the level of physiologic sensitivity and reactivity that is the determining factor.

It is also important to realize that adolescence is a particularly stressful time for virtually all adolescents. It is a difficult time of life for most people, including people who seem to have everything going for them (like high intelligence and lots of school success).

If I were to describe the typical personality traits of the adolescents who develop protective physiologic reactions, here is how I would describe them: They are emotionally sensitive, very responsible kids. They care deeply about others. They take life seriously, including their obligations to be the best they can be. They put lots of pressure on themselves to perform well in school and to be liked by their peers. They worry about whether they are measuring up—not so much to the expectations of others, but to their own (usually very high) expectations of themselves. They drive themselves hard. They work hard and are high achievers. They worry very much about others and aim to please and care about pleasing. They are pretty hard on themselves—probably too hard on themselves. They often feel as though they are not adequately measuring up—and often carry this worry secretly and chronically. Lazy, insensitive, uncaring kids don’t develop a chronic fatigue/pain and sensory amplification disorder.

Musculo-Skeletal Pain Amplification Phenomenon (MSK-PAP)

What follows is a hypothesis regarding pain amplification. A musculoskeletal pain amplification phenomenon (MSK-PAP) represents a protective physiologic reaction in which that part of the person’s physiology that is responsible for sensing, processing, interpreting, and reporting pain to our consciousness (in short, our “pain-reporting apparatus”) goes into a state of overdrive–all in an effort to protect us, to let us know that it is concerned about us.

This pain-reporting apparatus consists, roughly, of our peripheral nerves, spinal cord, the “central pain processing center” within the brain, and the neurons (within the brain) that relay the central pain processing center’s ultimate message to our consciousness. In a pain amplification situation, most of the pain amplification is probably occurring within the central pain processing center. In a pain amplification situation, the central pain processing center becomes very active (hyped up), neurophysiologically—such that it sends very loud messages of pain to our consciousness. A person is at the mercy of what their “pain-reporting apparatus” ultimately reports to their consciousness. If that report/message is one of loud, screaming pain, then, that is what the person actually feels.

Why is the central pain processing center amplifying its pain message? It is doing so in an effort to protect us. As explained earlier, this represents a protective physiologic reaction. Our human physiology is not being mean and trying to hurt us; it is trying to help us. It is important to “listen to what our body (our human physiology) is saying.”

Patients, or their parents, are often skeptical or surprised that a chronic fatigue/musculoskeletal pain amplification phenomenon can cause such severe pain, or such severe fatigue (or both). They often think, “How can my child be having so much pain or so much fatigue (or both) without there being a worrisome disease process responsible?” My response to this question is as follows.

If I were to line up all of the patients we see in our rheumatology clinic—all of those with rheumatoid arthritis, all with lupus, all with other rheumatic diseases, and all with a chronic fatigue/musculoskeletal pain amplification disorder—and line them up according to the severity of the pain or fatigue they are having, it is kids with a chronic fatigue/musculoskeletal pain amplification phenomenon who are having the most severe pain and the most profound fatigue. Kids with a chronic fatigue/musculoskeletal pain amplification disorder often have pain and fatigue that is far greater than the pain and fatigue experienced by kids with the worst cases of arthritis or lupus. Not all kids with a chronic fatigue/musculoskeletal pain amplification disorder have that much pain or fatigue, but some certainly do. Some can be severely disabled by their pain and fatigue. So, I am never surprised by how severe the pain, fatigue, and disability can sometimes be with a chronic fatigue/musculoskeletal pain amplification disorder. And, it is very real pain, fatigue, and disability—nothing is being exaggerated. In fact, the sheer magnitude of the pain and/or fatigue is a good clue that the patient is suffering from a chronic fatigue/pain amplification disorder—especially when appropriately complete lab testing is normal and the patient looks healthy to the casual observer.

Summary

Physiologic chronic fatigue and pain amplification represent normal protective reactions on the part of our human physiology. Though such reactions wreak havoc with the quality of life, they do not involve processes that are capable of causing any bodily harm, and the reactions are totally reversible. Although these protective reactions make life miserable (temporarily) for us, our human physiology is not punishing us; it is kindly helping us. Our job is to recognize what our human physiology is signalling to us and to then help ourselves.

I once had a 13-year-old adolescent female patient with chronic fatigue, who, after listening intently to the above explanation about “protective physiologic reactions,” wisely said: “You mean my ‘human physiology’ is kind of like my inner Mommy? Like, my ‘inner Mommy’ worries about me and wants to let me know when it senses that something is wrong, including being stressed out? And, it keeps worrying about me (and signalling its worry) until I start dealing better with that stress?”

I replied that that is exactly what I meant. Our human physiology is very much like an “inner Mommy” who cares very deeply about how we are going through life and kindly gives us signals (fatigue, pain amplification, or both) that alert us to the need to take action and find remedy. Like a good mother, our “inner Mommy” will not stop sending those signals until it is convinced that the problem(s) has been accurately identified and is being effectively addressed.

Definitions

What is “fibromyalgia” and how is it related to a chronic fatigue/pain and sensory amplification disorder? “Fibromyalgia” represents a chronic fatigue/musculoskeletal pain amplification disorder. Fibromyalgia = chronic fatigue + musculoskeletal pain amplification. Usually, the musculoskeletal pain is widespread throughout the musculoskeleton, symmetrical. Throughout this article, I have avoided using the term “fibromyalgia,” because the term is so greatly misunderstood by so many people (including some physicians) and, therefore, has become largely unhelpful. The terms “fibromyalgia” and “chronic fatigue/musculoskeletal pain amplification disorder” can be used interchangeably. I prefer not to use the term fibromyalgia.

What is “chronic fatigue syndrome” and how does it relate to a chronic fatigue/pain and sensory amplification disorder? Chronic fatigue syndrome represents a chronic fatigue/pain and sensory amplification disorder without the pain and sensory amplification component. In other words, in a “chronic fatigue syndrome” the primary protective physiologic reaction that is occurring is the reaction that causes fatigue; and little or no pain and sensory amplification is occurring.

Incidentally, the physiological reaction that is responsible for the fatigue (in a chronic fatigue syndrome) is probably a reaction that is the opposite of an endorphin reaction. You have probably heard of a “runner’s high,” which refers to the burst of considerable energy that is triggered by vigorous physical exercise. This exercise-induced burst of energy is due to the release of endorphins, which both energize the body and decrease pain. In the chronic fatigue syndrome, something opposite of endorphin release is probably occurring; perhaps, normal endorphin levels are not being released, or perhaps something that we might tentatively call “fatigueins” are being released. I hasten to add, however, that no such fatiguing physiological substances have, so far, been identified. Endorphins have been identified, but we do not know whether “fatigueins” exist.

Some patients have pain and sensory amplification but no chronic fatigue. In other words, the primary protective physiologic reaction that is occurring is pain and sensory amplification, and no fatigue-causing reaction is occurring. An appropriate label for that situation would be a pain and sensory amplification disorder. Sometimes, the pain amplification is widespread, involving much of the musculoskeleton, symmetrically—a musculoskeletal pain amplification disorder—as is the case in in fibromyalgia. Other times, the pain amplification is regional—i.e., affecting only one extremity, e.g. (like a foot). This would represent a “regional pain amplification disorder.” An ordinary tension headache represents a pain amplification disorder occurring in the head region.

Irritable bowel syndrome (IBS) represents a pain and sensory amplification disorder that is primarily occurring in the abdomen—causing, for example, abdominal discomfort, loose bowel movements (often alternating with constipation), and a sensation of bloating.

Some people experience several of the above-mentioned protective physiologic reactions to tension, sometimes all at the same time—chronic fatigue, musculoskeletal pain amplification, headaches, IBS, other sensory amplification.

Bear in mind, too, that pain from a disease process, like rheumatoid arthritis, can be heightened when, in addition, the patient develops an emotions-related pain amplification disorder. In such an instance the patient’s pain is partly due to the painful rheumatoid arthritis process but also due to pain amplification. Both can contribute to the pain—equally

or asymmetrically. So, when a patient with definite rheumatoid arthritis complains of severe pain (with or without fatigue), it should not automatically be assumed that all of their pain (and/or fatigue) is due to the rheumatoid arthritis.

Box or shade the following?

To Patients and Clinicians: To help us determine the value of the concepts presented in this article, please consider sending us a brief comment regarding the extent to which you found this article to be clinically helpful and effective, or not. You may send comments to: townsendpublisher1@yahoo.com