All in your head

The struggle is real – or is it?

I had a realisation recently, one of those proverbial blinding flashes of insight that seems to arrive suddenly after much subconscious stewing: “It’s all in your head” doesn’t necessarily mean “It’s not real”. This is a personal stance with feeling behind it, and my feeling is essentially that being told that something is “all in your head”, or suspecting the same, can feel for the most part invalidating, isolating and even a bit cruel.

The specific example I had in mind was when people, both generally and sometimes even within the medical profession, use this to explain when somebody experiences physiological symptoms which seem to have no obvious physical origin – typical examples being chronic pain, fatigue or fibromyalgia. In this case, “It’s all in your head” usually implies “There’s something wrong in your head”, which, true or not, may be interpreted as “There’s something wrong with YOU”.

There is a sense of personal responsibility attached to this assumption, and hence a suggestion of blame and shame. It suggests you can’t sort yourself out and therefore feels to me like an indictment of one’s strength of character. Critically too, there’s the assumption that the problems in your head can’t be seen by anyone else (you’re alone in there, buddy), and if you came up with them, there’s a good chance that you’re imagining them.

“It’s all in your head”, in other words, to me usually suggests “It’s not real”, which is to invalidate someone’s personal experience – or at least to tell them they’re on their own.

The problem with personal experience, of course, is that science usually doesn’t trust it one bit. For the sake of objectivity, phenomena need to be observable from the outside. What goes on inside the mind is unobservable except to the subject – a sample size of one. Hence, “in your head” often seems like code for unreliable at best, imaginary at worst.

This isn’t to say that symptoms that get produced in the head aren’t measurable – anxiety symptoms, for example, are commonly assessed to establish fitness to work and for disability insurance. It is just generally more challenging both to comprehend the symptoms and to isolate the causes of chronic conditions that don’t link clearly back to external damage. It’s not even that mysterious – doctors have known about the neuroscience of persistent, non-specific pain for years – it’s just very complex.

More importantly, though, this post is about the individual experience of problems that are “all in one’s head”, and the particular burden of dealing with them, given how we understand our minds work.

A few important points: I’m not saying we should fully trust the veracity of everything that goes on in our minds. I’m also not suggesting we should ignore thoughts, and especially not emotions. I also want to be clear that I’m not attempting to include clinical conditions, psychoses or hallucinations here. I am not a psychiatrist or psychologist; I’m just fascinated by the nature of the mind and the problems we understand or assume to be “mental” – and the popular connotations and misunderstandings that go along with this.        

So, to begin properly, how do we even understand illness and pain as being either in or outside the head?   

The Black Box

Where are our mental problems? When something feels broken in our psyches, it’s not so easy to locate in the same way that we locate physical pain. If I am suffering from a problem that is supposedly mental, can I point to my head and say the problem is there – the “pain” is there? This implies the pain is, well… me. Or “me” is elsewhere. 

One of the essential issues at play is that, at least in Western medicine, we’ve been trained to see the brain and body as separate, a paradigm known as the Cartesian model. Since the time of Descartes – the philosopher after whom the model was named – there has been considerable research into the connections between the two. Nonetheless, the Cartesian model persists. I think it is generally easier for us to accept the notion that some experience originates in the physical or chemical processes of the body rather than the head. Why? Because the head is a black box. And unfortunately, it seems, we are each alone inside that black box.

Well, here’s the thing: “It’s all in your head” is right, but it is also wrong. It is wrong, but not in the way you might think. “It’s all connected to your head” might be a more accurate alternative. Or, better yet: “Your head is not all in your head”.

No brain, no pain: The neuroscience of pain

The “neuromatrix” theory was put forward by psychologist Ronald Melzack (PhD) to explain the nature of pain and its subjectivity in particular. According to the traditional, or Cartesian model, pain comes from the site of some sort of injury. We hurt because of tissue damage. The brain and nervous system act as pain receptors, and pain is objectively measurable according to the extent of the damage. The problem with this theory? There is no consistent correlation between tissue damage and the experience of pain. One early clue as to the limitations of the Cartesian model was that it didn’t explain the phenomenon of phantom limb pain, where amputees experience pain in arms and legs that are no longer there.

The neuromatrix model, on the other hand, explains that pain is in fact produced in the central nervous system – that is, the brain and spinal cord. More specifically, various parts of our central nervous system interact to produce our experience of pain, including the limbic system, the insular cortex, the somatosensory cortex, and even the prefrontal cortex. The experience of pain has cognitive, attentional, emotive and even social components.

And we all know this already. We hurt more or less depending on whether we think the pain is temporary or potentially never-ending; whether we believe it’s a harmless scratch or a life-threatening injury; and whether we are feeling well or unwell, stressed out or distracted or motivated by something else at the time.  In short, how we experience pain depends on how we manage to make sense of it. 

Speaking of sense-making, there are even potential links between pain resilience – if I can call it that – and a concept known as Sense of Coherence (or SoC, developed by Anton Antonovsky). SoC is defined as “the extent to which one has a pervasive…though dynamic feeling of confidence that your environment is predictable and things will work out as well as can reasonably be expected”. In other words, if you feel both in control of your life and optimistic in your outlook, you’ll have a reasonably high SoC – and you might cope better with pain. SoC is a combination of your natural coping style, resources and support, and because these things clearly relate to stress levels, and stress in turn moderates our pain threshold, it stands to reason that SoC may ultimately affect things like lower back surgery outcomes, the effectiveness of pain management efforts, and even vulnerability to depression.

It is in your head – and then some.

From a pain perspective, then, “it’s all in your head” is accurate – if we take the neuromatrix view and use an extended definition of “your head”. That is, one which includes the systems and wiring not just within the brain but outside and throughout the body. After all, even though it’s “Mission Control”, your brain can’t be neatly separated from the complex communication network of your nervous system. (Fun fact: your body contains approximately 45 miles of nerves).

There is also, of course, the even-further-extended definition which includes the microbiome, or the ecosystem of bacteria in our gut which plays a vital role in many aspects of healthy functioning, both physical and mental (if we’re still using that dichotomy), and which has been dubbed our “second brain”. (Fun fact 2: your microbiome weighs roughly the same as the grey matter in your head). 

Where else would it be?

All of this causes us to re-examine what we mean by “real” when it comes to physical suffering. When we can locate pain in our foot, it seems “real” because we can point to it – but we’re still experiencing the pain in terms of chemical reactions that are processed in our heads (and/or minds and conscious awareness). All pain is generated by the brain (or nervous system) – in other words, it’s “real” because it’s in your head.

(We could of course take a sidebar at this point to further debate what the hell “real” means anyway, and about how much actually exists outside of our imaginations. Corporate brand values, the nation state, monetary value, negative numbers – all these are concepts, and none of it would be possible without imagination, let alone the image of Ryan Gosling as a centaur riding on a rainbow surfboard. They only exist as “real” because we share them, as collectively agreed fantasies. (Re the Ryan Gosling image: you’re welcome).)

And does the same thing apply to what I’ll call here “psychic” pain? In other words, what about the problems that are generally accepted to be all in our heads, like depression and anxiety? Do they also appear outside the black box of the cranium?

There’s ample evidence that pain or suffering caused “in the head” has corresponding physical symptoms. Heartache might be considered mental (while, ironically come to think of it, a headache is somehow thought of as physical, right?…), but it is in fact experienced in the body (Broken Heart Syndrome is an actual thing). And did you know that we experience social pain in much the same way as we experience physical pain? A study found the same areas of the brain lit up when subjects recalled feelings of rejection as when they experienced the equivalent of spilling hot coffee on themselves.

What about other aspects of our experience, which we may take for granted as being in more or less under our control, but which are actually pretty complex? Something like our energy levels?

The problem isn’t in your head – it might be in the field.

Certainly most of us don’t understand the science behind the role of our minds in complex conditions like chronic pain, but the medical field may also still be catching up – not necessarily in knowledge but perhaps in their approach. This is based on the experience of a friend of mine, whom we’ll call Amy, who struggled with chronic fatigue for three years and went to more than a handful of medical specialists before finally finding what can best be called a complex resolution to her problem.

Medical specialists who deal with anything other than the brain are typically focused on treating tissue primarily – and, of course, primarily the tissue they specialised in. This is a massive generalisation, and it makes sense because this is what doctors train for for years (they specialise for a reason, obviously). But while there has been an increase in awareness of the mental components of people’s conditions in the last decade, Amy still came up against the old Cartesian paradigm of body-vs-brain/mind with some of the specialists she consulted. Some seemed to operate as proverbial hammers, trying to find nails everywhere, where nails represented the tissue they specialised in treating. For example, when Amy went to a neurologist, they struggled to see her problem outside the “fibromyalgia” box – even though she clearly told them she had no pain. Communication may have played a role in that specific interaction, but here’s where it gets interesting:

Amy herself knew about the neuroscience of pain before her own symptoms started, and certainly learned more about it as they progressed. She knew about the neuromatrix model and the process of “central sensitisation” (to simplify hugely, this is where pain persists even after initial trauma has healed because the nervous system remains in a heightened state of reactivity – it’s a protective mechanism, our “alarm system” in overdrive). She was aware of the fact that pain is modulated by the central nervous system and by one’s state of mind; also, that our responses and wiring can be changed through neuroplasticity. In short, she understood that her problems might be in her head – in the best, most progressive and potentially empowering sense of the term.

Was this knowledge helpful? Looking back, Amy reckons that she was definitely better off than someone who knew nothing about neuroscience. Such a person may have panicked because they would most likely have been left with: “There’s nothing wrong with me” (and then: “So there must be something wrong with me”). Her position, by contrast, was that she knew that there was an explanation for what she was feeling, even if they could find nothing wrong physically. 

Of course, having knowledge about what you’re experiencing doesn’t magically fix it or make it any easier. Amy wound up in the emergency room several times believing that she was having a heart attack, but was told each time that there was nothing wrong with her heart. Once again, it was her system in overdrive – but knowing this doesn’t stop a racing heart from feeling like the end is nigh. Even when you have a (tentative) diagnosis to work with, there is still the day-to-day reality of treatment, which can be essentially experimental, and in Amy’s case amounted to ongoing “pacing” cycles: taking naps every half an hour and trying to increase the gaps in between. Try fit a sense of normality into a life more or less defined by proactive energy management.

But here’s how her journey ended, leading to an important final piece of the puzzle.

Everything comes together – sort of.

Amy had had problems with her tonsils for years. It was something she had wondered about, as something that might somehow be related to her fatigue, but didn’t actively pursue the issue (after all, who would suspect their tonsils?). One day, though, after enough bouts of tonsillitis, she had a tonsillectomy – and then, out of the blue, her energy levels got better. There were a few other contributing factors that crystallised for her around the same time, but essentially it seems that there was some local, low-grade inflammation or infection that was linked to a generalised, chronic immune system response, which led to her feeling exhausted 24/7.

The cause of the problem – or at least, the reason it persisted for so long – was suddenly revealed to be “physical”. In short, it was post-viral fatigue, or something very close to it. But for three years she had gone on the assumption that her problem, while not entirely mental, could be mentally mastered. And this assumption may have had its own drawbacks.

Ownership, self-blame and acceptance

While she started with the reassurance that this wasn’t something she was just imagining, Amy then took responsibility for being able to get better – and this came with its own pressures. She acknowledges that she blamed herself for not treating her body right, essentially asking herself what she had done to get herself to that point.   

The perception that “I must be able to control this; I must get my act together” surely adds stress to suffering because it’s close to “This is my fault”. This is perhaps reflective of society’s other most persistent paradigm: that what happens in your mind is all yours, and all because of you. It’s important here to state that these things are never a case of either-or. For example, with chronic conditions, even though the core issue might not be psychological, psychotherapy can still be helpful as part of treatment.

One positive aspect of Amy’s journey was finding a specialist who was able to treat her holistically and with an appreciation of the fact that healing is a complex and personal process. With this understanding, problems like chronic pain aren’t caused by one thing but by several physiological, psychological and emotional factors. There’s original tissue damage and then there are current and ongoing stressors; there’s the nervous system, and then there’s also the immune system at play. All of these factors contribute to what is known as overall “load on the system”, and they are ultimately difficult or impossible to neatly separate.

Amy observed that while we’re very used to “getting our act together”, especially regarding our physical health, there’s not a lot of awareness around the importance of being mentally kind to ourselves. And that she was able to be kind to herself only once she gained a sense of acceptance. She added: “Socially we are taught that discomfort is bad, whereas I’ve learnt it’s OK to feel physically and mentally really uncomfortable.”

While our mental state clearly affects our reality, it seems to be the case that if something is neurological, it doesn’t necessarily mean it’s “mental” or under our conscious control. The idea that we are a complex system – in ways we don’t even fully understand – that can take an indeterminate amount of time to heal – in ways that we aren’t necessarily aware of, let alone can’t even see – is frankly frightening. This is perhaps why we persist with assuming control, assuming responsibility. But maybe we need to watch out for when we cross the line between “I can control this” and “I am responsible for this” – and, perhaps, rather replace it with “I can accept this. I can work with this. I can support this”.

With great thanks to my friend Amy (not her real name).