慢性疼痛
《心理韧性》慢性疼痛,页面无弹窗的全文阅读!
情绪和生理上的痛苦走的是相同的神经回路。[15]因此，就像我们可以通过压抑情绪来加剧生理疼痛一样，我们也可以通过处理情绪来减少生理疼痛。尽管疼痛并不存在于“我们的脑海中”，但未得到化解的情绪还是会加剧我们的疼痛。
饱受慢性疼痛之苦的美国人超过了一个亿。慢性疼痛不仅会让人感到压力，令人衰弱，耗尽精力，同时也会增加预期压力——例如，当我们担心疼痛永远不会好转时，它可能会导致我们丧失能力或因此失去工作。
对不少人来说，慢性疼痛始于受伤或事故，但在伤病痊愈之后，这种疼痛还是会持续很长一段时间。在没有明确诊断的情况下，它很可能会带来灾难化的效果。因为这很容易创造一种恶性循环：实证研究表明，灾难化会让疼痛变得更加强烈，因此会让人感到更加疲惫，同时也会增加疼痛演变为慢性疼痛的可能性。[16]灾难化放大疼痛的事实说明，疼痛既有生理上的因素，也有心理上的因素。
实际上，每当经历生理、情感或社会等方面的痛苦时，我们都会激活大脑中相同的疼痛网络。[17]这个网络包括部分岛叶和前扣带皮层，我们在第12章讨论过这两个区域，它们在调节应激唤醒水平和情绪方面发挥着重要作用，而MMFT练习也被证明可以调节这两个方面的水平。
正如第2章解释的那样，在高压环境下工作的人可能倾向于通过躯体化来表达情绪痛苦，因为和寻求心理或情绪上的帮助相比，寻求生理上的帮助让他们产生的羞耻感相对较少。[18]还记得2003年入侵伊拉克前有关美国第82空降师的研究吗？[19]与没有作战经验的士兵相比，面对即将到来的部署带来的压力，老兵往往会产生包括慢性疼痛在内的相对较多的生理症状，并且会否认情绪上的痛苦。而慢性疼痛则是我在教学中观察到的最常见的失调症状之一。
从文化上看，我们往往会相信痛苦是由伤病或身体损伤引起的，但最近的研究则显示了更为复杂的情况。医生们早就明白，慢性疼痛可以在脱离身体损伤的情况下存在。例如：85%的腰痛患者没有任何诊断上的问题；相反，许多有椎间盘突出问题（腰痛的常见原因）的人却根本没有疼痛感。[20]
由于情感上的痛楚和生理上的疼痛共享的是同一个疼痛网络，而且使用了相同的大脑神经回路，所以它们会相互作用。在患有慢性疼痛的人身上，这些回路会变得高度敏感，也就是我们通常所说的疼痛通路的中枢敏感化（central sensitization）。最近的研究表明，中枢敏感化来自身心系统的系统性和慢性炎症。
以下事实突显了这种复杂的相互关系，大约半数的重度抑郁症患者同时存在慢性疼痛问题，而65%的慢性疼痛患者也曾经历过重度抑郁症。[21]更糟糕的是，抑郁和慢性疼痛一同增加了失能、药物滥用和自杀的风险。例如，在“9·11”恐怖袭击事件之后经历战争的美国老兵中，他们的慢性疼痛和药物滥用问题明显关联着自杀念头和暴力冲动。[22]
不幸的是，大多数美国人应对慢性疼痛的方法通常是无效的，而且还会助长无力感，将生存脑推向创伤性压力。
尽管大型制药公司出售许多药品来“解决”慢性疼痛问题，但这些药剂很少能够有效地治愈这种症状。更糟糕的是，几乎各类止痛药包括羟苯基乙酰胺，以及阿司匹林和布诺芬等非甾体抗炎药（NSAID）的长期使用都会增加痛感受器的超敏感化，还会增加肠道通透性（“肠道渗漏”），破坏微生物群的健康，加剧炎症问题。[23]我将在第17章对此做进一步讨论。阿片类药物（如维柯丁、Percocet[24]和吗啡）和苯二氮平类药物（如劳拉西泮、地西泮、阿普唑仑和氯硝西泮）等都有这些缺点，同时它们也很容易让人成瘾，导致了药物滥用和美国阿片类药物泛滥的问题。
而在另一方面，很多人求助于手术，这么做可能代价不菲且有风险。疼痛通常会在手术（即大家熟知的安慰剂效应）后暂时有所缓解，但是之后往往会比之前加剧，同时让人感到无助。例如，大约20%的背部手术患者在做了昂贵的手术之后依然饱受慢性疼痛之苦。[25]同样，在相当严格的对照研究中，治疗与关节炎有关的膝盖疼痛的关节镜手术比安慰剂的作用大不了多少还往往会让患者更快地产生置换膝盖的需求。
那么我们该如何找到应对慢性疼痛的能动性呢？我将在第17章就减少系统性炎症和重新平衡我们的肠道菌群提供具体的建议。现在，我想提供一些有关如何熟练应对强烈的身体感觉的建议。
首先，我们要认识到，当你的应激水平超越耐受窗时，比如当你睡眠不足、不知所措或情绪紧张时，疼痛通常会变得更加严重。慢性疼痛是失调的一种表现。因此，通过使用解除应激反应的工具让你回到耐受窗内，并快速减轻疼痛。例如，获得更多的睡眠和锻炼，吃得好一些，进行G＆R练习。
其次，你可以调整G＆R练习，使之适用于出现紧张和疼痛的部位。例如，你现在有颈部疼痛的问题就可以非常缓慢地转动脖子，直到你感觉到它被拉住。缓慢伸展非常重要，因为这样你就不会在不经意间超越这个位置，当你拉伸到刚刚感到疼痛之处时，请保持不动，将注意力集中在那里。在保持这个姿态的同时，你的疼痛可能会暂时加剧，但随后就会有所缓解。
在注意到第13章谈到的释放症状时，你就会知道这种释放已经产生。你也可以根据相同的原理，用网球或高尔夫球按压特别酸痛或脆弱的部位。如果你可以忍受90秒的不适感，那么这通常也会起到释放的作用。
你也可以利用这种G＆R拉伸方法的变化形式来补充以身体为基础的治疗，比如感觉运动心理疗法和体感疗愈等。你还可以从身体锻炼中获益，因为这种活动可以让你的身体回归生物力学的基准状态，同时实现更深层次的肌筋膜、能量和情绪上的释放。
再次，我们中的许多人都会通过阻断来应对慢性疼痛，然而抑制和对抗我们的疼痛会消耗大量能量。我们可以缓慢地训练自己让生理疼痛进入我们的意识，这样我们便可以释放此前用来阻断疼痛的能量。
为了谨慎地应对疼痛，你首先必须培养自己的注意力控制力，比如进行接触点练习。当你开始培养注意力控制力时，重要的是要采用相对没有痛感的姿势。例如，很多有背痛问题的人发现，在进行接触点练习时，保持平躺、双膝并拢屈起的姿势可以最大限度地减少你练习时的疼痛。让注意力一次又一次地回到接触点的感觉上有助于向生存脑发出信号，让它知道你是安全的、稳定的、舒适的。当生存脑产生安全的神经感知时，它便可以帮助你缓解疼痛。
一旦培养了注意力控制力，你便可以直接应对疼痛问题，培养痛感忍受力。需要明确的是，这种练习最好在你感觉相对有精力、约束力和调适力的时候去做，例如，你可以把它当作清晨的第一件事。
你可以从关注一个中性的目标开始，比如接触点上的声音或感觉。接着你可以将注意力转移到刚刚能感受到痛感的地方。将注意力放在痛感最强的地方是没有帮助的，这只会让生存脑产生危险的神经感知，从而触发更多应激反应和疼痛！
当你注意到疼痛的感觉时，重要的是区分真实的生理感觉（如阵痛、灼烧、刺痛或发热感）和思考脑对疼痛的描述。尽可能将注意力从任何有关疼痛的想法中转移出来，并将其保持在你的感觉上。
当你过度关注疼痛的感觉时，你只需将注意力重新转移到那个中性的目标上。在练习的时候，你可以让注意力在中性目标和疼痛感之间来回切换数次。
在关注疼痛的时候，你可能会注意到出现应激反应的迹象，比如心率加快、呼吸急促、恶心、口干、手心出汗或胸闷等。如果出现这样的情况，请将你的注意力从疼痛转移到接触点的感觉上，接着再进行一轮G＆R练习。
实际上，慢性疼痛常常与我们尚未释放的未得到化解的记忆胶囊和未完成的防御策略有关。有时，当我们关注疼痛时，我们便会触及其中之一。但这并没有什么关系。我们只要利用G＆R练习来释放它即可。
然而，如果这种情况经常出现，那么我强烈建议你找一位接受过感觉运动心理疗法或体感疗愈等以身体为基础的治疗技术训练的治疗师。他们可以帮助你安全地度过这个阶段，化解记忆胶囊，而且比你自己这么做更为有效。
不管怎样，当你练习关注疼痛时，随着时间的推移，你将能够提高自己忍受不适的能力。继而更强的挑战耐受力也将改变你对疼痛的认知。你因此感受到的痛苦和恐惧将会变得更少。这就是为什么基于正念的干预措施已被证明能够减轻疼痛强度和减少与疼痛相关的痛苦。当我们可以毫无畏惧地专注于某种生理感觉时，我们的疼痛感自然就会减少。
由于情绪和生理疼痛采用的是相同的神经回路，因此你可以利用本章中有关情绪部分的方法直接应对潜在的情绪问题。你可以与治疗师合作。你也可以记录你的疼痛，让疼痛来传递信息：写下一个问题，然后让“疼痛”借助你的非惯用手写下答案，这通常会让你内心的“批判者”走开。虽然这么做听起来很奇怪，但我的个人经验告诉我这真的有用。
最后，你可以记录自己对疼痛产生的任何限制性想法（比如你在生理上“能做”什么，“不能做”什么），然后用小实验来检验这些想法。这些想法是对的吗？在这个过程中，你可以将“不能做”的事情转成“能做”的事情，尽量减少疼痛给你日常生活带来的负面影响。在下一章里，我将进一步介绍同样适用于限制慢性疼痛的方法。
[1]本节的观点深受我的几位杰出导师的影响，特别是阿迪雅尚帝和罗德尼·史密斯。我非常感激他们的教导。
[2]Daniel J. Siegel, The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are (New York: Guilford, 1999), chap 4; Bruce S. McEwen and Elizabeth Norton Lasley, The End of Stress as We Know It(Washington, D.C.: Joseph Henry, 2002), 36-37; R. J. Davidson, D. C. Jackson,and N. H. Kalin, “Emotion, Plasticity, Context, and Regulation: Perspectives from Affective Neuroscience,” Psychological Bulletin 126, no. 6 (2000): 890-909.
[3]Pat Ogden, Kekuni Minton, and Clare Pain, Trauma and the Body: A Sensorimotor Approach to Psychotherapy (New York: Norton, 2006), 11-14;Siegel, The Developing Mind, chap. 4; E. Halperin and R. Pliskin, “Emotions and Emotion Regulation in Intractable Conflict: Studying Emotional Processes within a Unique Context,” Political Psychology 36, no. SI (2015): 119-150.
[4]Antonio Damasio, Descartes' Error: Emotion, Reason, and the Human Brain(New York: Penguin, 1994), chaps. 8, 9.
[5]J. N. Druckman and R. McDermott, “Emotion and the Framing of Risky Choice,” Political Behavior 30, no. 3 (2008): 297-321; T. Brader and G. E.Marcus, “Emotion and Political Psychology,” in The Oxford Handbook of Political Psychology, 2nd ed., edited by L. Huddy, D. O. Sears, and J. S. Levy(Oxford, UK: Oxford University Press, 2013), 165-204; Halperin and Pliskin,“Emotions and Emotion Regulation in Intractable Conflict”; J. Renshon, J.J.Lee, and D. Tingley, “Emotions and the Micro-Foundations of Commitment Problems,” International Organization 71, no. SI (2017): S189-S218; E. A.Stanley, “War Duration and the Micro-Dynamics of Decision Making under Stress,” Polity 50, no. 2 (2018): 178-200; Karl E. Weick, Sensemaking in Organizations (New York: Sage, 1995), 91-105.
[6]G. A. Bonanno “Loss, Trauma, and Human Resilience: Have We Underestimated the Human Capacity to ‘Thrive after Extremely Aversive Events?” American Psychologist 59, no. 1 (2004): 20-28.
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[8]Braswell and Kushner, “Suicide, Social Integration, and Masculinity in the U.S. Military”; Stanley and Larsen, “Emotion Dysregulation and Military Suicidality since 2001”; E. B. Elbogen et al., “Violent Behaviour and PostTraumatic Stress Disorder in U.S. Iraq and Afghanistan Veterans,” British Journal of Psychiatry 204, no. 5 (2014) 368-375; Elbogen et al., “Risk Factors for Concurrent Suicidal Ideation”; G. Green et al., “Exploring the Ambiguities of Masculinity in Accounts of Emotional Distress in the Military among Young Ex-Servicemen,” Social Science and Medicine 71, no. 8 (2010): 1480-1488;Y. I. Nillni et al., “Deployment Stressors and Physical Health among OEF/ OIF Veterans: The Role of PTSD,” Health Psychology 33, no. 11 (2014): 12811287; R. P. Auerbach, J. R. Z. Abela, and M. R. Ho, “Responding to Symptoms of Depression and Anxiety: Emotion Regulation, Neuroticism, and Engagement in Risky Behaviors.” Behaviour Research and Therapy 45, no. 9 (2007): 21822191; S. Fischer, K. G. Anderson, and G. T. Smith, “Coping with Distress by Eating or Drinking: Role of Trait Urgency and Expectancies,” Psychology of Addictive Behaviors 18, no. 3 (2004): 269-274; A. L. Teten et al., “Intimate Partner Aggression Perpetrated and Sustained by Male Afghanistan Iraq, and Vietnam Veterans with and without Posttraumatic Stress Disorder,” Journal of Interpersonal Violence 25, no. 9 (2010): 1612-1630; J. E. McCarroll et al., “Deployment and the Probability of Spousal Aggression by U.S. Army Soldiers,” Military Medicine 175, no.5 (2010): 352-356; Q. M. Biggs et al.,“Acute Stress Disorder, Depression, and Tobacco Jse in Disaster Workers Following 9/11,” American Journal of Orthopsychiatry 80, no. 4 (2010): 586592; R. M. Bray and L. L. Hourani, “Substance Use Trends among Active Duty Military Personnel: Findings from the United States Department of Defense Health Related Behavior Surveys, 1980-2005,” Addiction 102, no. 7 (2007):1092-1101; I. G Jacobson et al., “Alcohol Use and Alcohol-Related Problems before and after Military Combat Deployment,” Journal of the American Medical Association 300, no. 6 (2008):663-675.
[9]见第5章，以及 Stanley, “War Duration”, Renshon et al., “Emotions and the Micro Foundations of Commitment Problems”, G. Lowenstein and J. S. Lerner,“The Role of Affect in Decision Making,” in Handbook of Affective Science,edited by R. J. Davidson, K. R. Scherer, and H. H. Goldsmith (Oxford, UK:Oxford University Press, 2003), 619-642.
[10]Weick, Sensemaking in Organizations, 91-105; Jennifer Kavanagh, Stress and Performance: A Review of the Literature and Its Applicability to the Military (Arlington, VA: RAND, 2005), 17-19, 32-33; Stanley, “War Duration”; Elizabeth A. Stanley, Paths to Peace: Domestic Coalition Shifts,War Termination and the Korean War (Stanford, CA: Stanford University Press, 2009), chap. 2; Daniel Kahneman, Thinking, Fast and Slow (New York:Macmillan, 2011), chaps. 3, 4; M. J. Dugas, P. Gosselin, and R. Ladouceur,“Intolerance of Uncertainty and Information Processing: Evidence of Biased Recall and Interpretations,” Cognitive Therapy and Research 29, no. 1(2005): 57-70; M. J. Dugas, P. Gosselin, and R. Ladouceur, “Intolerance of Uncertainty and Worry: Investigating Specificity in a Non-Clinical Sample,”Cognitive Therapy and Research 25, no. 5 (2001): 551-558.
[11]R. F. Baumeister et al., “Bad Is Stronger Than Good,” Review of General Psychology 5, no. 4 (2001): 323-370; P. Rozin and E. B. Royzman,“Negativity Bias, Negativity Dominance, and Contagion,” Personality and Social Psychology Review 5, no. 4 (2001): 296-320.
[12]Baumeister et al., “Bad Is Stronger Than Good,” 323. 其中作者在第362页指出：由于坏的影响超过好的影响的模式太多……在没有太多例外的情况下，我们可以认为坏的影响更大。
[13]表达式写作又被称为书面情感表达或书面情感暴露，是表露情绪的一种方式，其做法是围绕某个创伤或压力事件写出自己的情感和认知。——译者注
[14]J. W. Pennebaker and C. K. Chung, “Expressive Writing: Connections to Physical and Mental Health,” in The Oxford Handbook of Health Psychology,edited by H. S. Friedman (Oxford UK: Oxford University Press, 2011), 417437; J. Frattaroli, “Experimental Disclosure and Its Moderators: A MetaAnalysis,” Psychological Bulletin 132, no. 6 (2006): 823-865.
[15]Matthew D. Lieberman, Social: Why Our Brains Are Wired to Connect (New York: Crown, 2013), chap. 3.
[16]Gary Kaplan and Donna Beech, Total Recovery: Solving the Mystery of Chronic Pain and Depression (New York: Rodale, 2014), 180; Brian Resnick, “100 Million Americans Have Chronic Pain. Very Few Use One of the Best Tools to Treat It,” Vox, August 16, 2018, vox/scienceand-health/2018/5/1717276452/chronic-pain-treatment-psychology-cbtmindfulness-evidence.
[17]Lieberman, Social, chap. 3.
[18]Killgore et al., “The Effects of Prior Combat Experience”; C. W. Hoge et al,“Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care,” New England Journal of Medicine 351, no. 1 (2004): 13-22; C. W.Hoge et al., “Mental Health Problems, Use of Mental Health Services, and Attrition from Military Service after Returning from Deployment to Iraq or Afghanistan,” Journal of the American Medical Association 295, no. 9 (2006):1023-1032; C. W. Hoge et al., “Association of Posttraumatic Stress Disorder with Somatic Symptoms Health Care Visits, and Absenteeism among Iraq War Veterans,” American Journal of Psychiatry 164 (2007): 150-153; T.M. Greene-Shortridge, T. W. Britt, and C. A. Castro, “The Stigma of Mental Health Problems in the Military,” Military Medicine 172, no. 2 (2007): 157161; I. H. Stanley, M. A. Hom, and T. E. Joiner, “A Systematic Review of Suicidal Thoughts and Behaviors among Police Officers, Firefighters, EMTs,and Paramedics,” Clinical Psychology Review 44 (2016): 25-44; Stanley and Larsen, “Emotion Dysregulation and Military Suicidality since 2001”;C. J. Bryan et al., “Understanding and Preventing Military Suicide,” Archives of Suicide Research 16, no. 2 (2012): 95-110; Green et al., “Exploring the Ambiguities of Masculinity.”
[19]Killgore et al., “The Effects of Prion Combat Experience”.
[20]Resnick, “100 Million Americans Have Chronic Pain.”
[21]B. A. Arnow et al., “Comorbid Depression, Chronic Pain, and Disability in Primary Care,” Psychosomatic Medicine 68, no. 2 (2006): 262-268; W.M. Compton et al., “Changes in the Prevalence of Major Depression and Comorbid Substance Use Disorders in the United States between 1991-1992 and 2001-2002,” American Journal of Psychiatry 163, no. 12 (2006): 21412147; Kaplan and Beech, Total Recovery, 72-76, 92-97.
[22]Tang and Crane, “Suicidality in Chronic Pain”; Elbogen et al., “Risk Factors for Concurrent Suicidal Ideation.”
[23]Kaplan and Beech, Total Recovery, 78-79, 144-145.
[24]由日本远藤工业株式会社生产的一款药物，其主要成分是盐酸羟吗啡酮与对乙酰氨基酚。——译者注
[25]Resnick, “100 Million Americans Have Chronic Pain”; Kaplan and Beech,Total Recovery, 78-79, 56, 144-145, 89.